Date of incident: September 2020
Notice of incident number: 2020181890013
Employer: Hay farm

Incident summary
A worker performing maintenance on a hay mower was fatally injured when the mower dropped off the jack that was supporting it.

Investigation conclusions

Cause

• Jack slipped while worker was under mower. The worker was positioned under the mower, which was supported with a jack with a small base on an uneven grass surface. The mower shifted off the jack and dropped onto the worker.

Contributing factors

• Leak in hydraulic system. The hydraulic system used to raise the mower deck was leaking, allowing hydraulic fluid to be lost. This in turn caused the weight of the mower to load the jack, making it unstable.
• Failure to control energy sources. The jack was the primary source of support for the mower load. The jack was unsuited for this use; blocking and wheel chocks should have been used on the mower. The valves on the mower’s hydraulic system were not in the closed position, and one of them was leaking. As a result, the weight on the mower’s wheels became unbalanced, the jack slipped, and the energy of the elevated mower was released as it dropped onto the worker.
• Failure to follow manufacturers’ procedures. The operator’s manual for the mower stated that the valves on the hydraulic raising system should be in the closed position prior to any work being done under the mower. It also stated that before any maintenance is carried out, the mower must be parked on a solid, level surface. Both a warning sticker on the jack and its instruction manual stated that the jack should not be used to support equipment while working under it. The instruction manual for the jack also advised against using the jack to support or stabilize the load and warned that the equipment should be blocked and its wheels should be chocked.
• Lack of safe work procedures. The employer had no written safe work procedures and no standard procedures for maintenance. All maintenance was organized and carried out by the worker.
• Lack of training system and records. The employer had no training system to ensure that each worker was adequately trained to perform duties safely. The employer had no records of any training given to workers on the job nor any records of outside training taken by workers.

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