Abstract: At approximately 1:15 p.m. on May 2, 1997, Employee #1, who worked at a cemetery, attempted to hitch a garbage dumpster to a 22-year-old John Deere 850 tractor. He had worked at the cemetery for 30 years, and performed this task every week because it made emptying trash cans and picking up dead flowers much easier. On this day, Employee #1 was having trouble with the tractor hitch, so he turned off the vehicle and put it in neutral. He then became distracted by a woman who asked him for a flower can, and after getting one for her from the dumpster, he continued trying to raise the hitch, which was controlled by a lever on the right side of the tractor seat. The tractor needed to be running to perform this task, so Employee #1 went to the left side of the vehicle, pushed in the clutch with his left hand, and started the tractor with his right hand. He forgot, however, to check if the tractor was still in neutral; when he started it, the tractor moved forward and knocked him down. It ran over his chest, fracturing four of his ribs, and then continued moving toward a group of people. Employee #1 got up, ran to the tractor, and turned it off. He later stated that the tractor was well maintained, that he always checked the vehicle to see if it was in neutral, and that he routinely used the parking brake. Employee #1's injury was not reported to OSHA until May 6, 1997, because his manager was away. The accident was not reportable, but the employer was cited for lack of a written Injury and Illness Prevention Program (IIPP).