Inspection Detail

Inspection: 300802899 - Maria Medeiros Dairy

Inspection Information - Office: Fresno District Office

Investigation Summary

At approximately 7:00 a.m. Employee #1 was driving a tractor pulling a Kirby mixer wagon, Serial Number KRM01129. This particular piece of equipment holds 750 cubic feet of cattle feed. It is powered by the power take off (PTO) from the tractor. The standard operational procedure is to load the wagon with one thousand pound bales of hay using a loader. The wagon has four large augers on the inside that breakup the feed and mixes it with grain. It is then discharged through a side door of the wagon that measures 4 ft by 4 ft. The wagon is equipped with a shear pin in case there is a jam in the machine. The pin will shear and the augers stop. This eliminates the need for anyone to attempt to unjam the equipment while it is in operation. The top of the wagon "bows" outward to prevent accidental entry. The manufacturer of this equipment had trained Employee #1 in the operation. The dairy manager heard the tractor running. The equipment was located approximately 20 yards northeast of the back of the house. Approximately thirty minutes later the manager realized that the tractor was in the same location and still running. The employer came outside and saw Employee #1's cap on the ground. He also saw a shadow through the bottom of the side feeder door. The employer climbed the metal ladder on the side of the wagon and saw Employee #1 inside. The employer shut down the equipment and called emergency services. The employer stated that at the time of the accident all three scales on the wagon registered empty. The employer also said that the side door of the wagon was closed and that the wagon itself was empty of feed. At the time the employer shut down the tractor it had been at approximately half throttle. At approximately 8:29 a.m. the Sheriff's Officers arrived. After Employee #1 was removed from the feeder the officer inspected the bottom of the wagon for anything of value that would have caused the victim to reach to try to retrieve it. Nothing was found. The Sheriff's report states that the shoe prints on the wagon ladder appear to be those of Employee #1. There were also latent handprints facing downwards, on the inside of the wagons top edge. The officer then had the employer restart the equipment. There did not appear to be any malfunction of the equipment. The wagon itself measures 9 ft 8 in. at the top rail. There is a metal ladder attached on the left front portion. The top step is 5 ft above the ground. Employee #1 was 5 ft 7 in. tall. If Employee #1 were standing on the top step he would only have 11 in. of the top portion of his body above the rail. There was no reason to be on top of the rail or to enter the wagon itself. Employee #1 was killed.

Keywords: CONFINED SPACE, AGRICULTURE, FARM MACHINERY, LACERATION, TRACTOR