Abstract: Prior to 10:41 a.m. on September 9, 1993, Employee #1 had been operating a JD 2010 tractor, pulling a Freeman 330 baler in an alfalfa field with windrows oriented in an east-west direction. The tractor and baler were found stalled, headed into a railroad embankment that runs north to south opposite the east end of the field. The baler was found in the idle mode. The following scenario is assumed to have occurred. Employee #1 stopped, dismounted the tractor, and put the baler in idle for an unknown reason. He remounted the tractor, then realized the baler was still in idle mode. Employee #1 attempted to place the gear in neutral and dismount the tractor; however, it was still in gear. When Employee #1 released the clutch, the tractor, which was still in gear, lurched forward and either threw Employee #1 off or caused him to fall off as he attempted to dismount. (Note: there were two tractor tire marks in the dirt, approximately 48 feet from the last bale completed, caused by the tractor digging in either by a fast start or by a heavy load being applied too quickly.) Employee #1 was transported to Tulare District Hospital in Tulare, CA, where he was pronounced dead at 11:23 a.m. The cause of death was tracheal compression and cervical dislocation. ROPS and seat belt rules were not applicable.