Date of incident: October 2020
Notice of incident number: 2020165880043
Employer: Winery

Incident summary
A worker was operating an all-terrain vehicle (ATV) at a vineyard, down an 11% slope, when the ATV unexpectedly lurched ahead. The ATV and the worker travelled across two vineyard roadways and down two steep slopes before the ATV ran into a row of vines supported by strung wire. The worker was thrown from the ATV and seriously injured.

Investigation conclusions

Cause

• Operator error and lack of training. The worker had been provided with an orientation on the ATV’s controls as well as the ATV operator’s manual, but had not received formal training. Investigators believe the handbrake was applied — which engaged both the front and rear brakes — while the ATV was in 4×4 mode, causing the worker’s body to shift forward, his thumb to press the throttle lever, and the ATV to lurch forward with a large amount of acceleration.

Contributing factors

• Lack of formal occupational health and safety program. The employer failed to develop an effective health and safety program and to ensure worker safety by communicating that program to management and workers. The employer did not have any written instructions for working alone at the workplace, or other essential written instructions, which were necessary to ensure the health and safety of workers working in the vineyard.
• No hazard assessment at vineyard. The employer did not conduct a hazard assessment for the workplace to determine potential hazards associated with the land, equipment, and work processes. In the absence of an assessment, no controls were implemented with respect to equipment that was being used at the vineyard.
• Lack of safe work procedure for operating mobile equipment. The employer had a checklist for tracking pre-use inspections of some of the company’s mobile equipment, but it did not include the ATV at the vineyard. The employer did not have a written procedure for operating mobile equipment in the vineyard, detailing which equipment could be used, what personal protective equipment was required, and how to operate the machinery safely.

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