Inspection Detail

Inspection: 301994828 - Baton Rouge Tree Service

Inspection Information - Office: Baton Rouge Area Office

Investigation Summary

A Kubota tractor (Model No. L4200, Serial No. L4200D53375) with a Model 2345QT front end loader attachment was located in a maintenance shed at the rear of a building owned by a tree service firm. The tractor had been in the shed for some time and was not used regularly. It had previously been sent out to a job site for a couple of weeks. Since it was returned to the shed, the tractor had experienced starting problems. It had to be jump started by shorting out the starter terminals. Jumper wires had been attached to a handgrip over the rear tire and were on the ground near the rear tire. At about 4 pm on the day of the accident, a lumber truck lost its load in front of the employer's establishment. The truck driver went to the employer and requested assistance putting the load back on the trailer. The employer's mechanic went to get the tractor to aid the driver of the lumber truck. About 15 minutes later, a contract mechanic who was working in the maintenance area heard the tractor running and went to the back of the maintenance shed to see what was going on. He approached the tractor from the right rear side and saw that the tractor was operating in reverse, digging itself into a hole as it had run into a stack of lumber. The contract mechanic shut off the engine and brought the key back into the office. The contract mechanic and the general manager went back to the area where the tractor was. They saw nothing on the right side; but when they walked to the other side of the tractor, they saw the first mechanic lying on the ground with tire marks over his chest. He had been run over and crushed to death by the tractor. The police discovered jumper wires in the dead employee's hand. The contract mechanic indicated that when he had jump-started the tractor before, he had had to move out very quickly when it started. A supervisor had previously stopped the victim and another worker from jump-starting the tractor, explaining that it was hazardous to do so and that the tractor needed to be fixed. Jump-starting the tractor bypassed the safety control circuitry and allowed the vehicle to start in gear. The mechanic had been starting the tractor this way for some time and had showed a coworker how to do it. It is believed that the mechanic was run over when he jump started the tractor and could not get out of the way when it started in gear. He was under the tractor when it started, and its front wheels rolled over his chest crushing him. The dead employee was found with his head facing away from the rear wheel and his feet closer to the tractor, indicating that he was able to move away from the tractor after it ran over him.

Keywords: JUMP START, INTERLOCK, STARTED IN GEAR, CRUSHED, TRACTOR, RUN OVER