California Department of Health Services
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SUMMARY : CASE
192-164-01
A worker
on a dairy farm was waiting behind a field cultivator to attach
it to the back of a tractor. A cultivator is a piece of farm
machinery that has a row of metal teeth, set in a rectangular
frame, with a wheel at each end. When pulled by a tractor
the teeth break up the soil. This cultivator was set on its
wheels and two support poles, which kept it from tipping backwards.
The
worker stood close behind the cultivator. In front, a tractor
driver was lining up his tractor to this cultivator. The driver's
foot slipped on the clutch, and his tractor jumped backward
and hit the cultivator. One of the support poles broke, and
the cultivator fell over backwards and onto the worker. The
cultivator frame landed on the worker's hips and stomach,
separating his pelvic bones. He lay pinned by the cultivator
and in great pain until enough workers arrived to lift the
cultivator off him. He was taken to the hospital by helicopter,
and could not return to work for over two months.
How
could this injury have been prevented?
- Workers
should not stand in the path of moving equipment. They should
wait to one side until the equipment stops moving.
- Before
hooking equipment to the tractor, turn off the tractor engine
and set the parking brake.
- Make
equipment safe. Outrigger wheels will keep cultivators from
tilting over.
BACKGROUND
On June
26, 1992, NURSE staff identified an injury on a dairy farm
while reviewing records at a Level 1 Regional Trauma Center.
On June 17, 1992, a dairy worker was attaching a field cultivator
to the back of a tractor when the tractor jumped backwards
and knocked the cultivator off its support poles. The cultivator
fell on the worker and its horizontal frame pinned the worker's
hips to the ground.
A nurse
from the NURSE project interviewed the injured dairy worker
on July 17, 1992. The Senior Safety Engineer discussed the
incident with the dairy's personnel manager, who is responsible
for the dairy safety program, and investigated the scene of
the injury on August 5, 1992.
The
incident occurred on a farm with approximately 300 dairy cattle
and 700 acres of corn. The farm has 23 full- time employees.
The local chapter of a state dairy association uses a computer
software package to produce written injury prevention programs
for its members, and the dairy farm used one of these programs.
The Senior Safety Engineer reviewed the program and noted
it addressed all seven points included in Title 8 California
Code of Regulations 3203 -- Injury and Illness Prevention
Program. (As of July 1, 1991 the State of California requires
all employers to have a written seven point injury prevention
program: 1. designated safety person responsible for implementing
the program; 2. mode for ensuring employee compliance; 3.
hazard communication; 4. hazard evaluation through periodic
inspections; 5. injury investigation procedures; 6. intervention
process for correcting hazards; and 7. a health and safety
program.)
The
injury was not reported to the California Occupational Health
and Safety Administration (Cal/OSHA), and was not investigated
by Cal/OSHA.
The
injured dairy worker had worked on this farm for 26 years.
The personnel manager told NURSE staff that short safety meetings
are held in the field every two weeks. However, the injured
dairy worker said that because of his long experience he did
not need, and had not received, safety training.
INCIDENT
On June
17, 1992, at approximately 4:30 p.m., a 53 year- old Portuguese
male dairy worker was hooking a field cultivator to a tractor.
The tractor was going to pull the cultivator across a new
field of corn to dig shallow irrigation ditches. The cultivator
was built on the dairy farm. It consists of a rectangular
frame of horizontal bars about 20 feet wide. Vertical bars
attach to the bottom of the frame to form teeth that break
up the soil. Two metal wheels, mounted five feet in from either
side, create the irrigation furrows.
When
the cultivator sits on the two metal wheels it is unstable,
and can tip forwards or backwards. Factory- manufactured cultivators
are built with a support system, sometimes with outrigger
wheels at either end of the horizontal frame to keep the cultivator
from tipping. This cultivator, built on the farm, had a metal
pipe mounted on each side of the frame, projecting down and
backwards. The cultivator was propped on these pipes, keeping
the frame from hitting the ground.
The
dairy worker stood behind the cultivator and waited to connect
the cultivator to the pull bar of a tractor. A pull bar is
a metal bar attached to two support arms mounted one on each
side of the tractor axle. The height of the cultivator can
be adjusted by raising and lowering these arms hydraulically.
The worker stood behind the cultivator because he found it
easier to reach over the cultivator and connect it to the
tractor from the rear.
The
tractor driver was lining up the tractor with the cultivator.
With the tractor in reverse gear, the driver's foot slipped
off the clutch pedal and the tractor jumped backwards, striking
the cultivator. The impact broke the pin that connected one
of the support pipes to the cultivator frame. With one support
pipe gone the cultivator tilted backwards. As it tilted the
rear edge of the frame knocked the worker down and pinned
him to the ground at his lower abdomen.
The
worker was pinned for 3-4 minutes, when the farm owner's son
and his friends saw the pinned worker as they drove by the
equipment yard. Five men, including the tractor driver, tilted
the cultivator up and the injured dairy worker crawled out.
The farm owner's son used his truck radio to contact the farm
owner, who called 911.
The
Emergency Medical Services (EMS) was called at 4:46 p.m. A
paramedic team arrived at 4:52 p.m., and a California Highway
Patrol helicopter arrived at 5:02 p.m. He was short of breath,
and complained of severe pain to his lower back and abdomen.
The paramedics gave him oxygen and started an IV. At 5:25
p.m., he was transported by helicopter to the emergency department
of the Level 1 Trauma Center, arriving at 5:32 p.m.
The
injured dairy worker had no fractures or internal organ damage,
but the weight of the cultivator bar falling on his lower
abdomen had separated his pelvic bones. A small amount of
blood was found in his urine, although there was no apparent
damage to his kidney or bladder. The injured dairy worker
was admitted to the hospital for further observation and evaluation.
After
three days in the hospital he was up and walking. The injured
dairy worker was discharged and given an appointment for follow-up
with an orthopedic physician in two weeks. He was advised
to remain home, on medical disability, for at least one month
and to avoid all lifting. At the time of the interview, he
complained of pain and had not returned to work. At the end
of August he was feeling better but had not returned to work.
PREVENTION STRATEGIES
- Workers
who are working as a team need to be sure there is constant
communication and visual contact between themselves. In
this incident, the dairy worker and the tractor driver were
working together to connect the cultivator to the tractor.
Tractors are loud equipment and may interfere with verbal
communication between workers. The injured worker should
have waited for a signal from the tractor driver before
he approached the cultivator to put the connector pins in.
- Standard
operating procedures should ensure that workers never place
themselves in hazardous situations to complete a work task.
In this incident, the dairy worker stood too close to a
heavy piece of unstable equipment, which itself was in the
path of a moving tractor. The farm's work procedure should
require workers to wait to the side and out of the path
of moving equipment until it comes to a complete stop and
has been turned off. If the worker had stood to the side
of the tractor and cultivator until the tractor was turned
off, he would not have been knocked down and injured when
the tractor struck the cultivator.
- Tractor
engines should be shut off before connecting equipment to
the tractor. The tractor driver should have turned the tractor
off much sooner and set the parking brake on the tractor
before signaling the dairy worker to begin hooking up the
cultivator. If the tractor had been shut off then, it would
not have lurched backwards, causing the cultivator frame
to fall on the worker.
- Employers
should consider safety engineering when building or modifying
equipment. Because this cultivator did not have side, stabilizing
outrigger wheels, it was not as stable as a commercially
manufactured cultivator. In addition, the pins connecting
the stabilizing bars to the frame sheared at the tractor
impact. If the cultivator had been built with stabilizing
wheels, or with two-inch pins connecting the support pipes
to the frame, the tractor would not have been able to knock
the cultivator over and onto the worker.
FURTHER INFORMATION
For further
information concerning this incident or other agriculture-related
injuries, please contact:
NURSE
Project
California Occupational Health Program
Berkeley office:
2151 Berkeley Way, Annex 11
Berkeley, California 94704
(510) 849-5150
Fresno office:
1111 Fulton Mall, Suite 212
Fresno, California 93721
(209) 233-1267
Salinas
office:
1000 South Main St., Suite 306
Salinas, California 93901
(408) 757-2892
Disclaimer
and Reproduction Information: Information in NASD does not
represent NIOSH policy. Information included in NASD appears
by permission of the author and/or copyright holder. More
NASD Review: 04/2002
This
document,
CDHS(COHP)-FI-92-005-19
,
was extracted from a series of the Nurses Using Rural Sentinal
Events (NURSE) project, conducted by the California Occupational
Health Program of the California Department of Health Services,
in conjunction with the National Institute for Occupational
Safety and Health. Publication date: October 1992.
The
NURSE (Nurses Using Rural Sentinel Events) project is conducted
by the California Occupational Health Program of the California
Department of Health Services, in conjunction with the National
Institute for Occupational Safety and Health. The program's
goal is to prevent occupational injuries associated with agriculture.
Injuries are reported by hospitals, emergency medical services,
clinics, medical examiners, and coroners. Selected cases are
followed up by conducting interviews of injured workers, co-workers,
employers, and others involved in the incident. An on-site
safety investigation is also conducted. These investigations
provide detailed information on the worker, the work environment,
and the potential risk factors resulting in the injury. Each
investigation concludes with specific recommendations designed
to prevent injuries, for the use of employers, workers, and
others concerned about health and safety in agriculture.
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