Date: 11 July 1997
SUBJECT: Tractor/Baler Operator Killed in Entanglement
An 80-year-old full-time farmer died after being caught under
a baler. The victim worked closely with his son on the 300-acre
farm. He was working alone, driving a tractor with a baler attached,
in an 8-acre field during a midafternoon in May. Having completed
a portion of the field in the morning, the victim returned to
the field after lunch to complete the task. Rain was forecast
and the remainder of the field would take 4-5 hours to complete.
The victim=s son went
to a nearby town to pick up parts for the round baler while the
victim used a square baler to bale the previously cut alfalfa.
About 5:00 pm the victim dismounted the tractor to clear a bale
from underneath the baler; he had inadvertently run over it. He
depressed the clutch, took the tractor out of gear, set the parking
brake, left the engine running, and dismounted the tractor. He
walked to the side of the baler, bent over and reached with his
left hand under the baler in front of the baler wheel. The tractor
and baler were parked on a gradual downward slope. Because the
PTO was still running, the baler was jerking forward as the flywheel
continued to rotate. The pulsating movement of the baler caused
the tractor to inch forward as the victim was reaching underneath.
The victim=s right arm,
being used to support his weight as he reached with his left,
was run over by the baler wheel, trapping him. His clothing then
became entangled in a rotating pulley adjacent to the baler wheel.
The victim was strangled by his shirt as it wound up tight. He
was discovered by his son a few hours later. Emergency medical
responders came to the scene, the coroner was called, and the
victim was pronounced dead at 7:10 pm. In order to prevent similar
occurrences, FACE investigators recommend that:
On 23 May 1997, an 80-year-old farmer died of traumatic asphyxia
after becoming entangled in a pulley on the side of a square baler.
On 24 May, KY FACE was notified by a Community Partners for Healthy
Farming (CPHF) nurse of the farm fatality the previous day. On
16 June a FACE investigator, accompanied by the CPHF nurse, traveled
to the scene. Interviews were conducted with the deputy coroner
who handled the case, the victim=s
son, and an equipment dealer. The case was later discussed by
phone with the EMS paramedic who responded to the call. Photographs
were taken of the tractor and the baler. Photographs taken by
the deputy coroner were viewed. The manufacturer's safety department
was called and an agricultural engineer was also consulted.
The victim in this case had farmed all his life in the same south-central
Kentucky region. He helped his son, who had been the primary farm
operator for several years. They grew alfalfa hay, wheat, corn
and soybeans, and had several head of beef cattle. The farm is
bifurcated by an interstate highway so that 175 acres are on one
side of the highway and 125 on the other. Visual contact between
the two portions is not possible. On the day of the incident the
victim was dressed in long pants, heavy duty long sleeved shirt,
T-shirt and work gloves. It was warm and sunny. He had complained
of knee pain although this was not unusual and no significant
medical history was reported. He was taking no prescription medications.
The 1973 Ford 3000 diesel tractor (38 hp) was not equipped with
a ROPS, a seatbelt, or a PTO guard. The victim had purchased the
tractor new. It was one of three Fords he owned and was in fair
condition for its age. At the time of the site visit the tractor
wheels were spread to the maximum width to facilitate the plowing
of corn. The brakes and parking brake were functioning properly.
This model tractor has a two-stage clutch where partial depression
disengages the drive gear and complete depression disengages the
The baler being used in this case was a 1970 Ford Model 530 square
baler. It was purchased by the victim new from a dealer who had
used it as a demonstration model. A pulley guard had been included
in the sale with the baler; however, it was never installed and
so was not on at the time of the incident nor at the time of the
site visit. According to an equipment dealer, the tractor and
the baler were compatible with respect to horsepower and weight
of the baler. Although the farmer had a round baler, he still
used the square baler two or three times a year. At the time of
the incident, the round baler was being repaired. On the left
side of the baler (see Figure 1) were two exposed pulleys, one
above the other, just forward of the rubber tire. A belt between
the pulleys drove the pick-up tines and the feeder teeth. The
lower pulley measured 13" across; its lowest part was 9"
from the ground. The distance between the rubber wheel and the
pulley was 2".
For this operation the tractor was usually operated in second
gear with the engine running about 1800 RPMs. This allowed the
PTO to rotate at 540 RPMs. With this speed, the plunger in the
baler compressed once each second.
Because of the plunger action to compress the hay, the baler had a tendency to creep forward, pulsate rhythmically, and push slowly, forcing the tractor forward. It pulsated once per second. The baler was in fair condition for this age equipment.
The 8-acre irregular and contoured field of hay had been cut a
few days prior to the incident. It was a gently rolling field
adjacent to an interstate highway. Wind rows curved with the contour
of the land. A fence separated the highway easement and the hay
field. The field was dry on the morning of the incident, so the
farmer and his father (the victim) decided to bale the hay using
the square baler, since the round one was being repaired. Rain
was forecast for the evening. After lunch, the son went to town
for a round baler part and the father returned to the 8-acre field
to finish the baling that had begun earlier in the day.
At about 5:00 pm the victim was nearly finished with the task.
As he began to turn downhill and to the right, evidence at the
scene suggests he ran over a bale or partial bale that became
lodged under the baler. He then depressed the clutch part way,
taking the tractor out of gear. Next he set the parking brake
on the left wheel. He dismounted the tractor and walked to the
side of the baler with the exposed pulleys. He knelt down just
forward of the wheel and with his left hand reached under the
baler to clear it out. In doing so, part of his clothing became
entangled in the exposed pulley, drawing him in tight against
the wheel and the pulley. His clothing wrapped so tight it cut
off his airway.
At 6:20 pm the victim's son and grandson went to the field to
help complete the job. As they approached the field they noticed
something was wrong because the tractor and baler were still running
and no one was on the tractor. Seeing that his father was entangled
in the pulley with his hand under the wheel, the son got on the
tractor, disengaged the PTO, and backed up slightly to free him.
He then phoned 911 to summon emergency medical assistance.
EMS was called at 6:32 pm and arrived at the scene at 6:46. Two
paramedics and one EMT responded. The coroner was called at 7:00
pm and arrived at the scene at 7:19.
Cause of Death
The death certificate listed the cause of death as traumatic asphyxia.
Toxicology was negative. No autopsy was done.
Recommendation #1: Machinery should be turned off by disengaging
the PTO before approaching the equipment.
Discussion #1: In this case the tractor engine was running,
the drive was disengaged but the PTO power shaft to the baler
was rotating. This caused the pulleys to continue rotating and
the plunger to continue to operate. The tractor therefore inched
forward and ran over the victim's hand, trapping him under the
wheel. Had the PTO been shut off, the pulleys would have stopped
and the forward movement of the tractor would have ceased.
Recommendation #2: Machines should be examined to ensure
that all moving components are properly guarded. If better shielding
is needed an authorized equipment dealer should be contacted to
determine if safety modifications have been engineered or made
Discussion #2: The guard for the baler came with the unit
when it was sold. However, it was never attached to the baler.
The shield would have prevented the clothing from being caught.
The distance between the wheel and the lower pulley was 2",
leaving little room for a guard; however, the guard would have
prevented any clothing from being "taken up" the pulley.
Safety guards should not be removed or modified. Guards should
not interfere with the tasks nor create additional sharp edges
or protruding parts.
Recommendation #3: Parking brakes should be set in unison
to minimize the possibility of rolling.
Discussion #3: Like most tractors, brakes on this tractor
operate independently to facilitate turning. They can be set such
that they can be applied one at a time or together. In this case
the brakes were set to operate independently. The victim applied
the left brake only, allowing the right brake to move freely.
With the lurching motion of the tractor caused by the plunger,
the tractor moved forward even though the left brake was engaged.
If the intent is to stabilize the position of the tractor, both
brakes should be applied equally.
Recommendation #4: Operators should not wear loose fitting
clothing when operating farm machinery.
Discussion #4: To minimize possible entanglement in rotating
parts clothing should be well fitting. Frayed clothes, jackets,
sweatshirts with drawstrings, and boots or shoes with long shoelaces
should be avoided. A shoelace, loose string, thread, flap of cloth,
or the corner of a jacket, as well as loose fitting garments,
can become entangled very easily.
Recommendation #5: Whenever possible, operators should
not work alone.
Discussion #5: The large proportion of occupational fatalities
that are attributable to machines such as the hay baler in this
case indicates the need for another person to be present when
such machines are operated. In many cases, immediate notification
of emergency medical personnel could make the crucial difference.
NIOSH Update, AFarm
Safety - Danger of Hair Entanglement in Hay Baler Drive Shafts,@
July 1992. DHHS (NIOSH) Publication No. 93-126.
NIOSH Alert, APreventing
Scalping and Other Severe Injuries From Farm Machinery,@
June 1994. DHHS (NIOSH) Publication No. 94-105.