Inspection Detail

Inspection: 308684547 - Fairbanks International

Inspection Information - Office: Omaha Area Office

Investigation Summary

On February 28, 2007, Employee #1 was working in a wash bay at a tractor implement dealership. He was cleaning the wash bay, using a Case 60XT skid steer, with Serial Number JAF0367534, to remove debris left behind due to the washing of tractors and implements. It appears that he was washing the skid steer bucket, when he attempted to crawl into the operator's cab. The bucket was not placed flat on the ground with the engine off, as the manufacturer recommends. In this case, the bucket was sitting on its nose, a position that prevented the loader arms from resting against the body of the vehicle as designed. With the bucket and arms in this position, it is more difficult to enter and exit the skid steer operator's cab. Employee #1 was attempting to crawl under the arms, when he slipped and fell face first into the cab. The Case 60XT skid steer is equipped with two interlocking safety devices. The first is a pressure switch located within the seat, designed to detect the presence of the operator. The second is a manually operated lap safety bar that the operator must pull down across his or her lap once the operator is seated and belted into the cab. In the unusual position that the employee took when he fell into the cab, he was inadvertently able to bypass both safety devices. This caused the loader arms to drop, pinching Employee #1 between the body and loader arm cross brace. He sustained fatal crushing injuries to his lower back and torso. Management indicated that Employee #1 had received on-the-job training (OJT) regarding the operation of the skid steer. That training, however, excluded the safe operating practices associated with the devices. A review of the operator's or safety manuals was not accomplished as part of the OJT.

Keywords: CLEANING, CONTROL LEVER, FARM MACHINERY, SLIP, CAUGHT BETWEEN, CRUSHED, SAFETY BAR, FALL, SLIPPERY SURFACE, FALLING OBJECT