Date of incident: August 2016
Notice of incident number: 2016170060023
Employer: Log hauling business

Incident summary
A worker was attempting to start a large tractor by bypassing the starter. He was standing on the ground between the front axle and the steps up to the tractor cab. The starter was actuated, the tractor moved forward unexpectedly, and the tractor’s rear wheels fatally crushed the worker.

Investigation conclusions
Cause

• Worker standing in hazardous area when tractor lurched forward: Once the tractor was started, its possible movement became a hazardous energy source that was not effectively isolated or controlled. The tractor’s brakes were not engaged, no wheel chocks had been used, and the tractor was in fourth gear. The worker had not ensured that the tractor’s transmission was placed in park or neutral before he exited the cab and before he attempted to start the tractor. Work was conducted in an area within the possible wheel path of the tractor, and the worker was run over by the rear dual wheels.

Underlying factors

• Defective condition of tractor: The neutral safety switch and clutch safety switch devices had been disabled, allowing the tractor to start even when it was in gear. This contributed to the sudden forward lurch of the tractor when the worker supplied electrical power to the starter. The starter solenoid was fused in the crank position. This defect, combined with bypassing the starter, meant that any power supplied to the starter could start the engine. The tractor was unsafe to use.
• Unsafe work practices: The worker did not adhere to the manufacturer’s instructions to start the tractor only from the operator’s cab. He also did not heed the manufacturer’s warning label regarding the danger of bypass-starting the tractor from the ground.