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 Case #02WV003-01
Part-time Farmer Dies Following a Tractor Rollover in West Virginia

4. The Victim Age/Sex: 57-year-old Male
Work Being Performed: Transporting a round hay bale
Incident Type: Tractor rollover
Experience: Very experienced and had maintained and operated the tractor involved for at least 20 years
Training: A self-employed mechanic and part-time farmer

5. The Employer
Type of Operation: Elderly self-employed farmer and landowner who the victim regularly assisted

6. The Environment Incident Location: Privately owned farm
Terrain: Sloping hillside, 40% grade
Date of Incident: January 26th, 2002

7. The Equipment
Machine: A 1939 FarmAll Model M tricycle front-end configured tractor
Other: The victim had been using the tractor for the past 20 years

8. The Equipment
The tractor was equipped with a front-end loader and a round bale spear attachment which weighed approxi-mately 400 pounds
The front-end loader bale spike attachment had only been used by the victim for the last two years

9. The Equipment
The tractor was NOT equipped with a rollover protective structure (ROPS)
The tractor was NOT equipped with a seatbelt

10. Sequence of Events
The victim was using the tractor to move a large round hay bale from the storage area.
The estimated weight of the bale was 800 pounds.

11. Sequence of Events
The victim elevated and began to transport the load to a feeding ring where the location required traversing a hillside.
The speed of transport was unknown.

12. Sequence of Events
The victim proceeded across the face of the slope with the left rear wheel on the downhill side.
Within 25 feet of the feeder ring, he began to elevate the load to clear the top of the ring.
As the total load of approximately 1,200 pounds was elevated, the tractor’s center of gravity (C.G.) shifted forward and downhill.

13. Sequence of Events
This graphic illustrates the normal C.G. and the shift which occurred due to a combination of sloped terrain and elevated front-end load.

14. Sequence of Events
This shift placed the C.G. outside of the tractor’s stability baseline, causing the tractor to roll downhill to the left.
The tractor rolled and landed on the victim.
The landowner came out to the field to check on the victim, and found him lying on the ground.

15. Sequence of Events
The landowner called the victim’s wife, who in turn called emergency services.
EMS, the county sheriff and medical examiner arrived and found no sign of life.

16. The Fatal Injury
The medical examiner estimated that the victim had died immediately after tractor impact.
The cause of death listed on the death certificate was blunt force trauma.

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

18. The Unsafe Condition or Act
Using a tractor without ROPS
Using a tractor without a seatbelt
Using a tricycle-configured tractor with an elevated front-end load
Hazardous placement of feeder rings which can compromise a tractor’s stability

19. 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.

20. Recommendation and Discussion
Recommendation: Convert tricycle-configured tractors to a wide front-end configuration.
Discussion: The victim was using an older tricycle-configured tractor which is inherently less stable, and leaves little room for maneuvering error. This instability is amplified with an elevated front-end load, and uneven or sloped terrain. These types of loads raise the C.G. and move it towards the tip of the stability triangle. On uneven ground, this allowed for the tractor to roll over towards the downhill side. Use of a wide front-end configured tractor may have stabilized the C.G. and therefore prevented the rollover.

21. Recommendation and Discussion
Recommendation: Prior to their placement, evaluate the location of feeding rings for hazards which can compromise a tractor’s stability during bale transport.
Discussion: Often to prevent damage to the field by the cattle, feeder rings are relocated. This particular ring was placed on the edge of the field and required bale transport across the face of a 40% graded slope. This severe of a grade should be avoided, in particular by load-bearing vehicles. More level feeder ring placement may have prevented this incident.

22. 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!

23. 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