Inspection Detail

Inspection: 123928103 - Lee Cardoso Dairy

Inspection Information - Office: Fresno District Office

Investigation Summary

At 8:26 a.m. on August 21, 1994, the manager of the Lee Cardoso Dairy was operating a Dresser payloader (front end loader), model 510B, serial #3380141C002289. He proceeded to corral #4 to repair a leaking coupling on a 3/4 in. water line, approximately 30 in. high, that was part of a metal fence separating corrals #3 and #4. The coupling had been leaking for 7 to 10 days and had created a mud/manure wallow approximately 25 ft by 16 ft and approximately 18 in. to 24 in. deep along the axis of the fence at the low point of grade. The payloader was positioned at right angles to the fence with the bucket approximately 2 in. from the fence, with front wheels at the edge of the wallow. The operator placed the loader in first gear and the direction control in neutral, and allegedly set the parking brake. The bucket was elevated approximately 6 in. to 12 in., and the engine was idling. The operator left the cab and crawled over the front linkage to the bucket, then positioned himself in the bucket. He was subsequently joined by Employee #1, who had crawled along the fence using the fence structure to stay out of the wallow. As they initiated repairs, the loader suddenly moved forward into the fence. The operator, who could see what was happening, was able to duck under the steel tubing of the fence and jump into the wallow to save himself. Employee #1 was pinned between the fence tubing and the top of the bucket. According to the operator, after the initial impact, Employee #1 took two steps then collapsed in the wallow. The operator removed Employee #1 from the wallow, placed him in the bucket, and transported him to his residence on the employer's property. Employee #1 was subsequently transported to Hanford Community Hospital, where he was pronounced dead at approximately 9:10 a.m. His body was released to the King's County coroner's office for autopsy. The cause of death was crushing blunt force trauma to the chest and heart. The parking brake and release button of the loader were inoperable when tested that afternoon by Mark Cardoso and CSE.

Keywords: CHEST, HEART, FRONT END LOADER, BRAKE, AGRICULTURE, LOADER BUCKET, PINNED, WORK RULES, EQUIPMENT FAILURE, CRUSHED