Agriculture Fatality Narrative: Operator Run Over by Combine Harvester When Engine Started by "Hot-Wiring"

Details

• Corporate Authors:
  Washington (State). Department of Labor and Industries
• Description:
  A 54-year-old operator was run over by a combine harvester after he "hot-wired" the engine and the combine moved in reverse. The operator was employed for 28 years at a wheat farm where his job duties included the operating of a combine harvester. He had 20 years' experience operating combines. On the day of the incident, the operator and the farm's two owners went to a field where the operator had left the combine for a week waiting for a replacement solenoid for the engine's starter. The operator wanted to move the combine to the farm's repair shop. The engine would sometimes start and sometimes not. The operator entered the combine's cab where he attempted to start the engine with a key in the ignition, but was unable to. For an unknown reason or by accident, he put the propulsion control lever in reverse before exiting the cab. He then went to the rear of the combine where the engine was located. He used an electrical cable to "hot-wire" the leads off the starter solenoid. The engine started and the combine began moving backward. He tried to climb down the ladder on the rear of the combine, but fell off it and landed on the ground between the tires. As the combine continued to move backward, the header ran over him. The combine stopped when it fell into a drainage ditch. He died at the scene from his injuries. REQUIREMENTS: Employers must furnish and require employees to use any safety devices and safeguards that are needed to control recognized hazards. All agricultural methods, operations, and processes must be designed to promote the safety and health of employees. RECOMMENDATIONS: FACE investigators concluded that, to help prevent similar occurrences: 1. Follow the machinery or equipment manufacturer's make and model operator's manual for operating procedures and maintenance to ensure the safety of operators. 2. Do not bypass machinery and equipment safety features by "hot-wiring" engines, as this disables safety mechanisms and may cause inadvertent movement of the machine, endangering workers. In this case, the combine's propulsion control lever had to be in "neutral" in order to start the engine with a key at the ignition. Because the engine was "hotwired" at the starter solenoid and the propulsion control lever was in "reverse" this safety feature was disabled. 3. Repair machinery and equipment as required so that unsafe practices are not used to start them. Description provided by NIOSH
• Subjects:
  • Agriculture
  • Environmental Exposure
  • Occupational Health
  • Risk Assessment
  • Risk Factors
  • Safety
  • Staff Development
  • Workplace
• Keywords:
  • Training
  • Safety
  • Safety measures
  • Safety practices
  • Hazards
  • Exposure levels
  • Risk factors
  • Protective measures
  • Safety education
  • Workers
  More +
• Series:
  Fatality Assessment and Control Evaluation Reports (FACE)
• Document Type:
  Text
• Funding:
  Cooperative Agreement
• Genre:
  Lay Publication
• Place as Subject:
  OSHA Region 10 ; Washington
• CIO:
  National Institute for Occupational Safety and Health (NIOSH)
• Topic:
  Workplace Safety & Health
• Location:
  North America
• Pages in Document:
  1
• NIOSHTIC Number:
  nn:20062421
• Citation:
  Olympia, WA: Washington State Department of Labor and Industries, 71-206-2021, 2021 Apr; :1
• Federal Fiscal Year:
  2021
• Performing Organization:
  Washington State Department of Labor and Industries
• Peer Reviewed:
  False
• Start Date:
  20050701
• Source Full Name:
  Agriculture fatality narrative: operator run over by combine harvester when engine started by "hot-wiring"
• End Date:
  20260630
• Download URL:
  https://stacks.cdc.gov/view/cdc/229100/cdc_229100_DS1.pdf
• File Type:
  [PDF - 250.03 KB]
• Collection(s):
  Fatality Assessment and Control Evaluation (FACE) Program ; National Institute for Occupational Safety and Health
• Main Document Checksum:
  urn:sha-512:2482fc557334494c434350b7db5625f812228b322e3a76360f59851a6f45f25c41cb524c85844fa19a019eb7c371284bdc7557de526a14e82aaa882cca98cdeb