KY FACE #97KY029
Date: 31 July 1997
SUBJECT: Rear Tractor Rollover Kills Farmer
A 67-year-old male farmer (the victim) died when the tractor he
was operating flipped over backward, pinning him between it and
another tractor. He and his 13-year-old grandson had been working
with a tractor and rotary mower, but got stuck in the mud of a
creek bed; approximately one-third of the rear tractor tires were
buried in mud. He had gotten a second tractor, attached a chain
from the rear of it to the front of the first tractor, and had
just begun to try and pull the tractor out when the incident occurred.
From evidence at the scene it appeared that his foot slipped
off the clutch, causing the tractor to lurch forward suddenly
and flip over backward. His grandson, who had been on the tractor
that was stuck, ran more than a mile to the house to summon help.
Emergency Medical Services (EMS) personnel arrived, found no
signs of life, and called the coroner, who pronounced the victim
dead at the scene. In order to prevent similar occurrences, the
KY FACE investigator recommends that:
On 24 March 1997, a 67-year-old farmer died of massive internal
trauma after his tractor rolled over. KY FACE was notified by
a phone call from the coroner who handled the case. On the advice
of the coroner the site investigation was postponed due to continuing
rain. On 8 July a KY FACE investigator traveled to the scene.
An interview was conducted with the coroner, who supplied photographs
from the sheriff's department and copies of the death certificate
and the ambulance run report. Photographs were taken of the two
tractors and the rotary mower at the home of the victim; however
the site where the incident occurred was not photographed because,
according to information provided by the victim's son, the constant
rain had made it unrecognizable and it was very difficult to reach.
The victim's son and grandson reside out of state.
The victim had recently retired from his job in private industry
and returned to the farm on which he was born and raised, and
which he had continued to farm part-time throughout his life.
He had recently acquired additional land, which he and his grandson
were clearing at the time of the incident. He was in good health,
and popular among his neighbors.
The tractor that the victim was using was a Ferguson Model TO-30,
manufactured in England between 1951 and 1954. It was a gas-powered,
four-cylinder tractor, approximately 25 horsepower. Total weight
was 2600 pounds. It was not equipped with a rollover protective
structure (ROPS) or a seatbelt. No counterweights were attached.
The left rear tire was about three-quarters fluid-filled; the
right was air-filled. The tractor was in fair operating condition,
although quite rusty.
The tractor that was stuck in the mud was an IMT Model 542 DeLuxe,
manufactured in Yugoslavia between 1986 and 1993. It was a diesel,
42 horsepower, weighing 4100 pounds.
On the day of the incident, the weather was clear and cool, but
recent rains had left the ground wet and very muddy. The area
where the victim and his 13-year-old grandson were working was
an old creek bed. They were using the IMT tractor with a rotary
mower attached to clear land. When this tractor became stuck
in the mud - its rear wheels were one-third buried in mud - the
victim returned to the house and brought back the small Ferguson
tractor to try and pull it out. He attached a chain near the
PTO shaft on the rear of the Ferguson and to a hook on the front
grate of the IMT. The Ferguson did not have a rear drawbar, but
its PTO shaft was low enough, and equipped with a hook, for attaching
the chain. As soon as he began to pull, the Ferguson tractor
lurched forward, reared up and flipped over backward, trapping
the victim between its left rear wheel and the front grate of
the IMT. According to the coroner and others at the scene, the
thick mud on the bottom of the victim's left boot was "sliced,"
as if his foot had slipped off the clutch, which was a single
metal bar rather than a rubber pedal. As soon as the tractor
flipped over, the grandson ran back to the house, approximately
one mile, and called 911. The EMS dispatcher received the call
at 3:26 pm. The trip to the house was 23 miles, but the terrain
between the house and the incident site was very rough. The EMS
workers arrived at the scene at 4:00 pm. Finding no pulse or
other vital signs, they placed a call to the coroner, who pronounced
the victim dead as of approximately 3:00 pm.
CAUSE OF DEATH
The death certificate listed the cause of death as massive internal
trauma. No autopsy was performed.
Recommendation #1: An appropriate tractor should be
chosen to perform the particular task at hand.
Discussion #1: The tractor that was stuck weighed 4100
pounds. The tractor the victim used to try and pull it out of
the mud weighed 2600 pounds, and was only about 25 horsepower.
It was not powerful enough to perform this task. If the victim
did not own another, more powerful tractor, perhaps he could have
borrowed one from a neighbor to perform this particular job.
Recommendation #2: All tractors should be equipped
with rollover protective structures (ROPS) and seatbelts.
Discussion #2: In this case, the tractor which rolled
over was manufactured by The Standard Motor Co., Ltd., of Coventry,
England, between 1951 and 1954. No listing was found for it in
directories of ROPS-kit providers, so it is possible that none
was available. Moreover, the tractor was so rusted that it might
not have supported a ROPS. This tractor, therefore, should have
been reserved for use under less hazardous conditions. Whenever
possible, operators should use non-ROPS-equipped tractors for
safer work areas and/or activities. Since 1985, as a result of
voluntary agreements among tractor manufacturers, virtually all
new tractors sold in the US have been equipped with ROPS and seatbelts,
which protect the operator by creating a "zone of protection."
Furthermore, many tractor manufacturers are currently offering
ROPS retrofit kits at cost to encourage owners of non-ROPS-equipped
tractors to have them installed.
Recommendation #3: Front-end counterweights should
be used to lower the center of gravity and improve traction and
Discussion #3: Additional weight on the front of the
tractor can substantially improve tractor stability. While it
is impossible to say that they would have prevented this rear
rollover, they are always worthwhile safeguards.
Recommendation #4: Tractors should be kept in safe
Discussion #4: The clutch on the tractor in this case
was a small metal bar. Originally it had a rubber pedal attached.
Evidence suggests that the victim's foot slipped off the clutch,
causing the tractor to suddenly lurch forward and flip over.
It is possible that replacement of the rubber pedal might have
Recommendation #5: Tractor operators should consider
environmental conditions and terrain and make necessary adjustments
to accommodate to them.
Discussion #5: In this case, the deep mud was
a major contributing factor. The mud caused the first tractor
to become stuck, and the mud on the victim's boot probably caused
his foot to slip off the clutch. If at all possible, the area
should have been avoided until dry weather arrived.
Murphy, Dennis J. 1992. Safety and Health for Production
Agriculture. St. Joseph MI: American Society of Agricultural