1. West Virginia Fatality Assessment and Control Evaluation

2. West Virginia Fatality Assessment and Control Evaluation
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)

3. Anatomy of a Tractor Incident 99WV025
Dairy Farm Worker Dies Following a Tractor Rollover in West Virginia

4. The Victim Age/Sex: 38-year-old Male
Work Being Performed: Transporting a round hay bale
Incident Type: Tractor rollover
Experience: Operated the tractor for the past 13 years and was very experienced
Other: Had performed the bale moving task with the tractor and its fork related set-up many times during this period

5. The Environment
Incident Location: A sloping field, on the employer’s property.
Terrain: Irregular, with a 15° grade
Date of Incident: May 24th, 1999

6. The Equipment
Machine: A 1965 John Deere 3020 equipped with a factory-installed model 46A end loader attachment
Other: The tractor was not equipped with ROPS or a seatbelt
Do these pieces of equipment still fit??

7. The Equipment
Additionally, a set of after market forks were chained onto the tractor to lift the bales, as is shown in the photo.
The white box in the photo represents the end loader bucket

8. The Employer
Type of Operation: Self-employed dairy farmer with a total of 7 employees.
Other: There was no designated safety director or formal written safety program, although the employer did indicate that “on-the-job” safety-related instructions were given when deemed necessary.

9. Sequence of Events
The victim was transporting a round hay bale for a routine cattle feeding.
The bale was being moved from the storage area, located next to a drainage ditch.
This arrangement allowed for an uneven travel/work zone on the ditch side of the bales.

10. Sequence of Events
The victim approached the pile on the tractor perpendicular to the ditch, engaged and elevated a bale.
The victim then reversed from the pile, and began to pull forward and parallel to the pile.
The victim began to pull away across the face of the 15° slope, with the right rear wheel on the downhill side.

11. Sequence of Events
The slope was littered, and lumpy with debris, creating an uneven travel surface.
The left rear wheel (on the uphill side) rolled over one of the lumps, shifting the tractor’s center of gravity (C.G.) forward and downhill.
This shift placed the tractor’s C.G. outside of the tractor’s stability baseline, causing it to roll downhill and to the right.

12. Sequence of Events
The tractor landed on the victim, pinning him to the ground.
Another worker heard the noise, looked up and saw the overturned tractor on the victim, then ran to the owner’s house.

13. Sequence of Events
As the owner checked for vital signs, the owner’s wife called
EMS arrived within minutes and the tractor was removed.
The victim was transported to the hospital where he was pronounced dead.

14. The Fatal Injury
The cause of death listed on the death certificate was multiple head, neck and chest trauma.

15. The Fatal Energy Source
The line represents the 15° grade.
The tractor was driving away from this perspective.

16. Center of Gravity (C.G.) Shift
This graphic illustrates the tractor’s C.G. movement as a result of elevating a front end load while traversing a hillside.
Once the C.G. moves outside of the stability base, the tractor can tip, and possibly rollover.

17. Center of Gravity (C.G.) Shift
This graphic illustrates the same C.G. movement when viewed from the rear.

18. Discussion What went wrong?
What were the unsafe conditions, acts or root causes?
What would have prevented this incident?
What do safety experts say about elevated front end loads?

19. The Unsafe Condition or Act
Using a tractor without ROPS.
Using a tractor without a seatbelt.
Using a tricycle-configured tractor over unsuitable terrain.

20. 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.
Owners of older model tractors should contact their county extension agent, equipment dealer or equipment manufacturer to determine if retrofit ROPS and operator restraint systems are available for their equipment. Such systems should be installed by the manufacturer or an authorized dealer.

21. Recommendation and Discussion
Recommendation: Convert tricycle-configured tractors to a wide front end configuration.
Discussion: Tricycle-configured tractors are inherently less stable and have stability baselines that leave little room for error. This instability is magnified when dealing with elevated front end loads such as hay bales. This, in conjunction with sloping terrain, use of a wide front end configured tractor may have allowed the C.G. to remain within the stability baseline and therefore prevented the rollover.

22. Recommendation and Discussion
Recommendation: Evaluate the work area for hazards which can compromise a tractor’s stability prior to each operation.
Discussion: The randomly distributed clumps of hay, which were a leftover hazard of previous moving activities, were littering the tractor’s work zone. These clumps turned a predictable working surface into an uneven and highly unpredictable working surface. This uneven terrain caused the tractor’s C.G. to be constantly changing. Evaluating the tractor’s work zone prior to operation may have given the operator opportunity to identify possible hazards.
Given the fact that the task being performed involved a front end elevated load in conjunction with sloped terrain, Instability is amplified when dealing with elevated front end loads, which can move/raise the C.G. The speed can greatly influence how quickly and how extreme the C.G. shift will be; especially when traversing a hillside. Using extreme caution and reducing speed may have allowed the C.G. to remain within the stability baseline and thereby prevent the rollover

23. Recommendation and Discussion
Recommendation: Evaluate the location and its terrain prior to establishing round bale storage areas.
Discussion: The bale storage area was next to a drainage ditch, and on 15° sloped terrain. Establishing a storage area where the travel/work zone is sloped, places the operator at greater risk for C.G. shifts. The risk is further increased if work zone activity involves elevated loads. Positioning the storage area on level terrain would have facilitated easier access to the bales and reduced the risk for C.G. shifts leading to rollover.

24. Did You Know That
An average of 6 tractor operators die each year due to rollovers!
Research studies have shown that for every work-related death there are 600 near misses !

25. And remember, you can make a difference!
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
Remember, this incident actually happened. Too many hard working loggers 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