Date: 19 December 1994
Subject: Retiree Dies After Tractor Overturns Into Creek
A 58-year-old retired factory worker and part-time farmer was
killed when the tractor he was operating overturned into a creek
and pinned him. At the time of the incident, the victim was mowing
a pasture along a creek bed. The tractor was not equipped with
a Roll Over Protective Structure (ROPS) or a seat belt. Attached
to the tractor was a five foot bush hog. About 3:00 pm the day
of the incident, the victim began mowing a 30 acre bottom land
pasture by entering a gate at the east of the pasture. The victim
drove in a westward direction across the center of the field toward
the west end of the field. Along the south and west edges of the
rectangular field was a creek and to the north a fence paralleling
a public roadway. Having reached the near western end of the pasture,
the victim began a cut parallel to the creek heading west with
the left side of the tractor bordering the creek embankment. As
the victim began the cut along the creek, the left front wheel
went over the edge, causing the tractor to roll over to the left
and turn over. The victim was pinned from the waist up under the
left fender in six inches of water. The victim was alone at the
time of the incident and was discovered two hours later by his
father and a farm hand. Investigators concluded that in order
to prevent future fatalities tractor owners and operators should:
Additionally, county officials should consider initiating a county-wide
911 emergency service
On November 3, 1994, a 58 year-old-male retiree was killed at
his father's farm while bush hogging a pasture. On November 6,
the FACE investigator learned of the incident in the newspaper.
An investigation was initiated at that time. On November 23, the
FACE investigator and the Occupational Health Nurses in Agricultural
Communities (OHNAC) nurse traveled to the scene to continue the
investigation. The coroner, deputy coroner, Emergency Medical
Service (EMS) personnel, and the victim's father were interviewed.
Measurements and photographs were taken at the scene. Photos taken
by the deputy coroner, the coroner's report, the autopsy and the
toxicology reports were obtained.
The victim grew up on this farm and left following high school
to live in a large city and pursue a career at a major manufacturing
company. He had returned to the farm frequently during his 32
year career with the manufacturing company, to help his father.
Twelve months prior the incident, the victim retired from the
manufacturing position and moved back to the farm. Along with
his father, he raised two acres of tobacco and a vegetable garden.
The remaining 158 acres was leased as pasture land. Repairing
fences, barns, equipment and mowing occupied most of the victim's
time since his retirement. He was familiar with the equipment
and the terrain and had mowed the pasture several times in prior
years. This was the second time this year this particular pasture
was to be mowed.
The farm has been in the family for over 50 years. It takes about
25 minutes to reach the farm which is located 14 miles from the
nearest town. Safety training was not conducted at this family
farm. Injury history was not readily available, however the victim's
father reported the victim had been in several motor vehicle accidents.
His experience on the tractor included many weekends during his
manufacturing tenure and more regular since his retirement.
The victim had a history of heart disease and was on Nitro-glycerin
and Vasotec. He had a history of alcohol abuse but according to
his father had not consumed alcohol for about 16 years. He was
a heavy smoker. According to the victim's father, he had lost
some of his right arm function due to back surgery some years
ago but this did not effect his ability to drive the tractor.
The victim was right handed. An autopsy showed a grade IV atherosclerosis
of the left anterior descending artery.
On Thursday, November 3, at about 3:00 pm, the victim began mowing
the bottom land pasture. Weather conditions were warm and partly
sunny. Driving a 1963 Massey Ferguson 35 Diesel Delux (36 hp pto)
tractor with a five-foot Woods three point hitch rotary bush hog,
the victim entered the pasture at the east end. The rectangular
shaped 30 acre pasture is fairly level with a few swampy areas
where water does not drain from the field. The south and west
edge of the pasture is demarcated by a creek. A nearly vertical,
seven foot, irregular shaped embankment parallels the creek. This
sandy loam, eroded edge washes out with heavy rains continually
changing the shape of the field edge. Only short grass holds the
treeless flat surface area. Water flows in a westerly direction
through a 15-40 foot wide flat rock creek bottom. Depths vary
from 6-24 inches. About 30 head of cattle roam the pasture.
Proceeding length-wise down the center of the rectangular field,
the victim drove toward the far west end of the pasture. A path
cut by the victim indicates this was the first cut through the
pasture. As the victim neared the west end he turned gradually
to the north along the embankment. The tractor's left front wheel
went over the seven foot embankment causing the tractor to roll
over to the left and into the creek. The victim was pinned from
the waist up under the left fender of the inverted tractor in
about 6 inches of water.
After two hours it was nearing dusk so the victim's father and
a farm hand began a search. They followed the trail cut by the
victim to the creek edge at the south west corner of the field.
Discovering the victim under the tractor they went to summon help.
Emergency Medical Service (EMS) received the call at 5:44 pm.
One EMT and one paramedic arrived at the scene at 6:06. The rescue
squad arrived about 5 minutes after EMS. A call was made by EMS
personnel to hospital dispatch to notify the coroner of the incident.
The coroner received the call at 6:15 and arrived at the scene
at 6:40. The victim was pronounced dead at the scene.
A Caterpillar 416 backhoe loader (62 hp, 13,572lbs.) was driven into the creek about 1500 feet from the incident site where a road passes over the creek. The backhoe has a boom lift capacity of 2600 pounds. With the assistance of the rescue squad, the tractor was lifted off the victim. He was loaded and strapped to a back board and lifted up the embankment. From there he was transferred by truck to an awaiting funeral home vehicle on the main road. He was later transferred a state medical facility for an autopsy.
The tractor suffered moderate damage in the roll over. Its air
intake stack was bent and the exhaust, having been modified to
point upward to accommodate tobacco setting, was broken off. Two
fenders were crumpled and the hood dented in the roll over. Wheel
measurements indicate front and rear wheels were spread the same
distance. There was no ROPS, Slow Moving Vehicle (SMV) placard,
or power take off shield. No weights were attached to the brush
guard on the front of the tractor. The left rear tire was fluid
filled, the right air filled. According to the victim's father,
the fuel tank was full at the time of the incident. When checked
by the FACE investigator the brakes and steering functioned well.
The two-year-old five-foot-wide Woods bush hog was not damaged
in the roll over. It was equipped with a pto shaft guard.
CAUSE OF DEATH
The cause of death was listed as compression asphyxia sustained
in a farm vehicle accident with roll over into body of water.
Injuries include bilateral rib fractures, pulmonary congestion,
cutaneous petechiae of the superior chest, neck and head. The
autopsy was negative for alcohol and drugs.
Recommendation #1: Tractor owners and operators should
contact their county extension agent, local equipment dealer or
equipment manufacturer to see if retro-fit rollover protection
and operator restraint systems are available for their equipment.
Discussion #1: The tractor in this incident, manufactured
in 1963, was not equipped with a ROPS or an operator restraint
system, which protects the operator in the event of a roll over.
ROPS first became available as optional equipment on farm tractors
in 1971. These safety features were not required on tractors until
1976, when OSHA standard 29CFR 1928.51 went into effect. This
standard required employers to provide ROPS and safety belts for
all employee-operated tractors manufactured after October 25,
1976. However, this standard does not apply to family farms or
farms employing fewer than 11 employees. Since 1985, as a result
of voluntary agreements by tractor manufacturers, all new tractors
sold in the US have been equipped with ROPS and safety belts.
(MMWR Jan.29, 1993) On this 1963 tractor, retro-fit ROPS and operator
restraint systems are available. Tractor owners should contact
dealers, manufacturers or county extension agents for information
on sources of retro fit ROPS and operator restraint systems. The
cost to retro-fit this tractor is about $750.00.
In Kentucky since January 1994, there has been only one documented
death where an operator was killed in a tractor roll over on a
tractor equipped with ROPS. In this case, the operator was not
wearing a seat belt. There have been 22 deaths from non ROPS equipped
tractor rollovers during the same period. In all of these cases,
ROPS would have saved the life of the operator.
Recommendation #2: Equipment should be kept in prime working
Discussion #2: In this case the 1963 Massey Ferguson was
in fair condition for its age. However, the rear tire weight distribution
was unequal. The left rear tire was fluid filled, the right air
filled. Two-hundred fifty pounds of additional weight on the left
side may have influenced the handling of the equipment. Equal
distribution of lateral weight by fluid filling both rear tires
is recommended. Although this in itself would not have eliminated
the fatal nature on this incident, it could have had a bearing
on the tractor handling properties.
Recommendation #3: Tractor owners should evaluate the terrain
before beginning any operation that includes machinery.
Discussion #3: Operators should evaluate the terrain and
select a suitable path considering slope, land conditions and
attachments. In this case, the pasture was level ground with a
hazard along the south and west edges. The irregular nature of
the bank due the erosion would suggest that the precise shape
would change between mowings. Even with prior experience in this
particular field, the victim may not have been aware of these
changes. Evaluation the conditions prior to starting the laying
out procedures may have informed the operator of potential hazards.
Effectiveness of Roll Over Protective Structures for Preventing
Injuries Associated with Agricultural Tractors. MMWR 42(03);
National Safety Council (1978). "Tractor Operation and Roll-Over
Protective Structures." Occupational Safety & Health
Data Sheets. I-622-Reaf. 85.
National Institute for Occupational Safety and Health (Jan 29,
1993). "NIOSH Reports on the Preventability of Tractor Rollovers."
Centers for Disease Control and Prevention. DHHS (NIOSH) publication