TO: Director, National Institute for Occupational Safety and Health

FROM: Iowa FACE Program

SUBJECT: 12-year-old boy dies from a tractor rollover in a roadside ditch -- Iowa.

Summary:

A 12-year-old boy working part-time for a farmer was killed when he lost control and overturned a tractor in a 12 foot deep roadside ditch. The victim was driving downhill on a slightly sloping gravel road, came to the bottom of the hill, and approached an uphill. At this point the road had a culvert and deep ditches dropping off sharply at the edge of the road. For some reason the boy drove too close to the right edge and fell into the ditch causing the tractor to roll completely. The tractor was approximately 10 years old and had no ROPS or seatbelt. The tractor was pulling an empty feed wagon which sheared off at the hitch and was also pulled into the ditch, however, did not overturn. The boy was crushed under the left rear wheel and fender of the tractor and died from asphyxiation due to crush injury. There were no obvious environmental factors contributing to the incident, nor failure of the equipment. However, the tractor’s seat was adjusted in the back position, making the distance from the seat to the brakes too long for this driver. The loader frame may have obstructed the drivers view of the front wheels making it difficult to see the exact position of the front wheel and the edge of the road.

Recommendations based on the FACE investigation were:

1.	All tractors used in hazardous conditions should be equipped with ROPS and a seatbelt. The hazardous conditions in this case include an inexperienced driver driving on a public road and having a front end loader on the tractor.
2.	Employers should comply with child labor laws regarding agricultural work declared hazardous by the Secretary of Labor.
3.	Employers should ensure that the machinery is in safe working condition and adjusted to meet the physical requirements of the operator.
4.	Employers should provide appropriate safety education and supervision for the employees.

Introduction

In 1995, a 12-year-old boy, working part-time for a farmer in Iowa died after he lost control and overturned a tractor in a roadside ditch. The Iowa FACE program became aware of the incident from a newspaper article and began an immediate investigation. Two investigators from the Iowa FACE program conducted a site visit, assisted by an Iowa OHNAC nurse. Other sources of information were the Iowa State Patrol’s report (including photographs), and interviews with farm employer and employees.

The employer was a family farm managed by two brothers. They also owned an implement dealership located ½ mile east of the farm. They hired the boy on a part-time basis for the previous 2½ months to do routine farm chores for their cattle operation. The boy was driving the tractor alone when the accident occurred. There were no direct eyewitnesses of the event although farm employees were at the scene within a few minutes.

There was no written safety program for this farm, and safety training was task specific and verbally taught. According to the employer, the boy was a good student and had read books on tractor safety before working on the farm. The tractor was approximately 10 years old, had approximately 80 horsepower and was equipped with a front end loader. The tractor had no ROPS or a seatbelt. The tractor was used both on the farm and at the implement dealership down the road. The boy had driven this tractor back and forth along this stretch of road more than 75 times in the past 2½ months without apparent difficulty.

Investigation

The boy was driving the tractor from the employer’s implement location to the farm site located ½ mile west along a fairly narrow straight public gravel road. He was pulling an empty cattle feed wagon. He drove downhill on a slightly sloping road, came to the bottom of the hill and approached an uphill. At this point the road had deep ditches and a culvert. The road had no shoulder, the steep bank started immediately at the edge of the road. About 25 feet past the culvert the road started a gradual uphill, where the tractor slipped into the ditch on the right side and overturned completely crushing the boy under the left rear tire and fender. The hitch to the feed wagon was sheared off leaving the feed wagon upright and partly in the ditch. The boy’s left boot had come off, and was stuck between the seat and the left fender. It is possible that he attempted to jump but got caught by his boot.

The road was straight, there were no obstacles on the road, no holes, bumps, or washboarding that could have made driving difficult. There was no passing traffic nor environmental conditions which caused the tractor to go into the ditch. The ditch was approximately 12 feet deep with a 40 degree slope to the bank. There was no shoulder on the gravel road, but it dropped off sharply into the ditch. The grass and weeds were less than 1 foot tall at this time and did not obstruct the edge of the roadway. The tractor had a front end loader (empty) which may have blocked the boy’s sight of the front wheel and the edge of the road. The seat was adjusted to the back making the distance from the seat to the brakes too long (40") for a five foot tall driver. The brake pedals were not coupled together and the play before the brakes engage was long (5"). Having an obstructed view and not being able to reach the brakes properly could have contributed to the accident.

The boy was alone when the accident occurred. An employee of the implement dealer (also a First Responder) noticed from a distance behind that the feed wagon was heading for the ditch and she was the first person at the scene. The boy was found pinned under the rear tire of the tractor, dead at the scene from crushing chest injuries.

At our site visit the tractor had been repaired and was being used as before without a ROPS. According to the employer this tractor is stored in an older garage with a low doorway height of about 7 ft. and therefore ROPS was never considered.

Cause Of Death

The cause of death from the Medical Examiner’s report was asphyxia due to crush injury due to tractor rollover accident.

Recommendations / Discussion

Recommendation #1: All tractors used in hazardous conditions should be equipped with ROPS and a seatbelt. The hazardous conditions in this case include an inexperienced driver driving on a public road and having a front end loader on the tractor.

Discussion: ROPS and a seatbelt installed on this tractor may have saved the boy’s life. ROPS provides a safety zone for the operator in case of an overturn and the seatbelt keeps the operator within this safety zone. Driving on a road involves an overturn hazard and therefore tractors driven frequently on public roads should be equipped with ROPS and a seatbelt. The wheel spacing (width) on the front and rear axles of the tractor was quite narrow (5 ft.), making it more unstable on slopes. The front end loader raised the center of gravity further, increasing the risk of overturning.

Recommendation #2: Employers should comply with child labor laws regarding agricultural work declared hazardous by the Secretary of Labor.

Discussion: Many children age 12 and younger are allowed to drive tractors on family farms. Learning this skill is considered by many as a natural part of growing up on the farm. However, assigning work duties for children involves a serious risk of exceeding their physical and psychological capabilities. Parents and employers should ensure that tasks assigned to children match their capabilities. The Secretary of Labor has declared operating a tractor over 20 horsepower to be hazardous, therefore requiring the tractor operators to be at least 16 years of age. In this case the operator was only 12, and therefore did not meet the requirement of the child labor laws. Even though a child is willing and appears able to perform the work, it is necessary for the supervisor to use judgment. Young inexperienced drivers will not have proper hazard recognition skills to work in hazardous conditions.

Recommendation #3: Employers should ensure that the machinery is in safe working condition and adjusted to meet the physical requirements of the operator.

Discussion: In this case the operator’s seat was adjusted in the back position, and therefore the distance from the seat to the brakes was too long (40 inches) for a five foot tall driver. The brake pedals had to be pressed 5 inches horizontally before engaging the brakes, which made the braking more difficult. Based on police photographs, the brake pedals were not coupled together which should be done for road travel. There was no skid marks or other evidence whether the driver failed to control the tractor because of these ergonomic factors, however, to prevent similar occurrence it is necessary for the driver to be able to reach all controls of the machine without difficulty.

Recommendation #4: Employers should provide appropriate safety education and supervision for the employees.

Discussion: According to the employer the victim was safety conscious and had read about tractor safety before working on the farm. He was instructed to stay on the right side of the road as he approached the hill. These instructions may have encouraged him to drive too close to the right edge causing the fall into the ditch. Proper education should be given to the employees, including hazard recognition. The employer should also provide adequate supervision and monitor the worker performance to ensure that the workers follow safe procedures.

___________________________________	__________________________________
Wayne Johnson, M.D.	Risto Rautiainen, M.Sc.Agr.
Trauma Investigator (FACE)	Coordinator
Institute for Rural & Environmental Health	Great Plains Center for Agricultural Health
University of Iowa -- Iowa City, Iowa	Institute for Rural & Environmental Health
	University of Iowa -- Iowa City, Iowa