1. West Virginia Fatality Assessment and Control Evaluation

2. The WVU Center for Rural Emergency Medicine, in cooperation with the National Institute for Occupational Safety and Health (NIOSH) and the West Virginia Department of Health and Human Resources, conducts investigations of fatal work-related injuries. The project known as FACE (Fatality Assessment and Control Evaluation) seeks to identify the factors that contribute to occupational fatalities. The FACE project will help in the development and use of improved safety measures for preventing fatal injuries in the future. For additional information, please contact Wayne Lundstrom at (304) 293-6682.

3. Anatomy of a Tractor Incident Case #02WV002-01 Dairy Farmer Dies Following a Tractor Rollover While Trying to Roll-start Tractor in West Virginia

4. The Victim Age/Sex: 44-year-old Male Work Being Performed: Attempting to roll- start a tractor Incident Type: Tractor rollover Experience: Owned, operated and maintained the tractor for the past 23 years Training: Had performed this maneuver 2-3 times/week for the past few years

5. The Environment Incident Location: On the victim’s dairy farm Terrain: Snow-covered farm road which traversed a hillside Weather: Cold and snowy (8 inches of recent snow accumulation) Date of Incident: January 8 th, 2002

6. The Equipment Machine: A 1979 Massey Ferguson Model 265 wide front-end configured tractor One of three tractors used on the farm

7. The Equipment The tractor’s electrical system was malfunctioning The roll-starting method had been used for 2 years The tractor was NOT equipped with a rollover protective structure (ROPS) The tractor was NOT equipped with a seatbelt

8. The Employer Type of Operation: Self-employed dairy farmer Other: Had been farming the property his entire life

9. Sequence of Events The victim mounted the tractor and began rolling down a snow-covered farm-road which traversed a hillside. As the tractor began to roll, a bump, rut or snow-covered irregularity caught one of the front wheels and canted the front-end to the right in a downhill direction.

10. Sequence of Events The dotted line represents the intended direction of the roll-start. The solid line represents the tractor’s actual path.

11. Sequence of Events The victim was unable to control the unexpected change in direction because the tractor had not yet started, and the hydraulically-controlled steering system had not engaged. The tractor left the road and began rolling down the hillside. As the victim approached another snow-covered road, approximately 75 feet below the first, he was able to start the tractor.

12. Sequence of Events The victim entered the second road while in a sliding left-hand turn. The tractor’s right front, and right rear wheels dropped off the four foot embankment below the second road. The tractor then rolled over sideways, landing on the victim, pinning him to the ground.

13. Sequence of Events The victim’s employee, who was assisting in the starting operation, witnessed the incident. He ran to the victim’s aid and tried to free him. Unable to move the victim, he called 9-1-1. EMS arrived at the scene of the incident and found no vital signs.

14. The Fatal Injury The coroner estimated that the victim died immediately upon tractor impact. The cause of death listed on the death certificate was chest trauma.

15. The Fatal Energy Source This photo shows the four foot bank which both the right front and right rear wheels dropped off, causing the tractor to roll and land upside-down on the victim.

16. Discussion What went wrong? What were the unsafe conditions, acts or root causes? What would have prevented this incident?

17. The Unsafe Condition or Act Using a tractor without ROPS Using a tractor without a seatbelt Operating a tractor with a compromised electrical system Operating a tractor during inclement weather and under hazardous road conditions

18. Recommendation and Discussion Recommendation: Equip all tractors with rollover protective structures and a seatbelt. Discussion: Preventing death and injury requires the use of ROPS and a seatbelt. OSHA requires that all tractors built after Oct. 25, 1976 for use on farms of 11 employees be equipped with ROPS and a seatbelt. In WV this may not apply to smaller family farms, but given the uneven terrain and environmental conditions, tractor owners should install ROPS and seatbelt.

19. Recommendation and Discussion Recommendation: Maintain all tractors in serviceable condition. Discussion: Tractor owners should realize the correlation between defective equipment and risk-taking. The tractor’s electrical system was damaged. Roll-starting tractors is a dangerous practice, particularly on machines with hydraulically-controlled steering mechanisms which yield little if any directional control until the tractor starts. Tractors should be inspected and serviced regularly. Had this tractor been operating correctly there would have been no need to attempt a risky roll-start and the fatality may have been prevented.

20. Did You Know That An average of six tractor operators die each year due to rollovers! Research studies have shown that for every work-related death there are 600 near misses!

21. Some Final Thoughts Remember, this incident actually happened. Too many hard- working farmers are losing their lives or being seriously injured in our beautiful state. In an effort to bring this number down, we are providing this information to you. Please share the lessons learned from this unfortunate event. Tell your buddies, your boss, your workers. Take a moment to look things over and ask yourself, “What if?” And remember, you can make a difference! West Virginia FACE