MIFACE INVESTIGATION REPORT: #10MI019 

SUBJECT: Farmer Died When He Fell From a Ladder 

Summary 

In the Winter of 2010, an 83-year-old 

male farmer died when he fell from a 

ladder in a cattle pen while he was 

replacing boards for a heifer pen 

(Figure 1). The decedent had noted 

that the nominal dimension oak 

lumber (2x4s, 2x6s) boards on the 

fence between the concrete cattle 

courtyard and the heifer pen “gave 

way” when pushed against. The fence 

was located on the north side of the 

heifer pen. The event was 

unwitnessed. Cattle were in the 

courtyard. The decedent 

disassembled an extension ladder and 

was using the 12-foot fly section (the ladder section that can be extended upward) to gain 

access to the fence boards. It appears he was using a battery operated drill, described as 

fairly new, to drill pilot holes for additional fasteners. When the decedent did not come 

back for dinner, his spouse looked for him. She found him lying on his side on the 

ground, unconscious but breathing. The ladder had fallen to the east. The drill bit had 

broken. His wife tried to use her cell phone to call a friend and emergency response, but 

her cell phone would not place the call. Finally, she was able to contact 911. A helicopter 

was summoned and the decedent was taken to a nearby hospital. He died the next day as 

a result of the injuries sustained. 

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Figure 1. View of incident scene 

RECOMMENDATIONS 

• Follow safe ladder work practices; extension ladders should not be separated and 

use ladders equipped with safety feet. 

• Clear unrestrained animals from work area prior to beginning work. 

• When using fasteners like nails or screws, drill appropriately sized pilot holes and 

use appropriately sized fasteners. 

• Ensure emergency response can be summoned on a timely basis. 

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INTRODUCTION 

A MSU Extension agent notified MIFACE personnel of this fatality. MIFACE contacted 

the decedent’s spouse who agreed to participate in the research program. MIFACE 

personnel conducted a site visit on September 23, 2010. The police report, medical 

examiner case report, and the death certificate were reviewed. An autopsy was not 

performed. The decedent’s wife permitted MIFACE to take pictures of a scenario reenactment of the incident. 

The decedent was raised on a farm, but worked in a non-farming activity until retirement. 

After the decedent retired, he bought a farm and raised short horn cattle. The farm 

comprised 250 acres. The decedent, at the time of the incident, had seven calves and 

seven heifers. The calves were raised for breeding purposes. The decedent sold the calves 

once per year, and occasionally sold the heifers. The decedent did not have employees. 

He had attended numerous MSU Extension courses, and was considered a “progressive 

farmer” by his community. His wife indicated that the decedent would ask her for help if 

he felt the job required her assistance. 

The decedent had past surgeries for his heart, back and eyes. He was a well-controlled 

diabetic, and strictly followed his prescribed insulin and eating regimen. 

INVESTIGATION 

On the day of the incident, the temperature was approximately 550

F with wind speeds 

from the north/northeast ranging from 9 mph to 16 mph. Wind gusts occurring near the 

time of the incident were approximately 20 mph. Minimal amounts of snow had fallen 

the previous week and the snow had melted. The concrete courtyard was dry. The 

courtyard sloped slightly downward. Measurements where the ladder was found: 58 

inches height from heifer pen floor to where he was drilling and 64 inches from concrete 

courtyard to board he was drilling. 

Due to the cool but not cold weather, the 

decedent was dressed in 6-inch lace-up 

Muck® boots with bottom treads, several 

pairs of socks, shirt, sweatshirt and hooded 

sweatshirt. He had eaten lunch and came in 

for a snack between 4:00 p.m. and 4:30 

p.m. He then returned to work. 

Barn maintenance was ongoing throughout 

the year. The decedent was getting ready 

for the birthing season and was repairing 

the heifer barn fence. He had tested the 

heifer pen fence boards, which were 

attached on the north side of the support 

heifer pen support poles (facing the cattle courtyard). The top of the lower fence board 

Figure 2. Fence board/post where some 

pilot holes had been drilled. 

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was 64 inches above ground level. The boards separated the heifer pen from the cattle 

courtyard. These boards “gave way” and were not attached securely (Figure 2). He 

gathered his tools; a fairly new battery operated drill and his favorite ladder, the 12-foot 

top section of an extension ladder that had been separated from the ladder base. 

The 12-foot fly section of the 

ladder had straight, not angled 

ends. It is postulated that the 

decedent was in the process of 

drilling pilot holes through the 

existing fence boards attached 

to the support posts or working 

on the building’s upper beam 

so he could place fasteners 

(nails or screws). He did not 

remove the cattle from the 

courtyard. It is unknown how 

high the decedent had climbed 

the ladder; it is unknown if he 

was placing support screws in 

the building beam or in the 

fence. It is unknown how he set the ladder against the fence; ladder may have been 

supported only be the lower fence rail or supported by both the lower and upper beam. 

Also unknown is the position of the ladder in relation to his work activity; it is unknown 

how far he may have been leaning to drill the 

pilot holes. Also unknown is if the ladder was 

placed so the ladder’s rung locks were at the top 

or near the ground (Figures 4 and 5 show both 

options). At some point during his work activity, 

he fell from the ladder and struck his head on the 

cement courtyard. 

Figure 3. Ladder used by decedent with no safety 

feet 

Heifer building 

beam 

When he did not return for dinner, his wife took 

her cell phone and went to look for him. She 

found him lying on his side to the west of the 

ladder, with his knees drawn up in the courtyard, 

like he was attempting to get up after a fall. He 

was unconscious, but breathing. The ladder had 

fallen to the east. His drill bit had broken. 

His wife attempted several times without success 

to contact a neighbor and emergency response. 

After several tries, she was finally successful in 

contacting emergency response. Based upon her 

description, emergency response called for a 

helicopter and an ambulance was dispatched. 

Figure 4. Ladder placed under 

(not supported) by the building 

beam and against fence railing 

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When the ambulance arrived, emergency responders placed the decedent in the 

ambulance until the helicopter arrived. She was not granted access to the ambulance. 

The helicopter transported the decedent to a nearby hospital where he died the following 

day. 

Several incident scenarios were developed: 

1. He had a medical emergency causing his fall. No autopsy was performed to rule 

out a medical emergency. 

2. While drilling, he may have struck a knot or 

nail with the drill bit, causing him to be 

pushed back and the ladder kicking out 

resulting in a fall from the ladder and the 

ladder to fall. 

3. One of the cattle pushed against the ladder, 

causing the ladder to move. He may have 

lost his balance and he and the ladder fell. 

4. One of the cattle came between the heifer 

pen and the ladder causing the ladder to be 

pushed away and the decedent and the 

ladder to fall. 

5. The top of the extension ladder segment was 

not placed against the heifer pen beam, thus 

supported only by the 2x4 fence board. The 

extension ladder segment had a straight cut 

and did not have safety feet so the ladder 

base was not flush with the concrete. The 

ladder base may have kicked out more easily 

as he was working and applying pressure to 

the drill (Figure 4). 

Figure 5. Top of ladder resting 

against the upper beam of barn 

6. Wind gust may have affected his balance on the ladder. 

CAUSE OF DEATH 

The cause of death as listed on the death certificate was craniocerebral trauma. No 

autopsy or toxicology was performed. 

RECOMENDATIONS/DISCUSSION 

• Follow safe ladder work practices; extension ladders should not be separated and 

use ladders equipped with safety feet. 

Although agriculture is exempt from many MIOSHA standards, farmers should use the 

standards to learn more about safe work practices. The MIOSHA Construction Safety 

Standard, Part 11, Fixed and Portable Ladders specifies the requirements for ladder use. 

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Extension ladders should not be separated. Using the upper section without angled feet 

defeats the function and safety of a modern extension ladder. Old wooden extension 

ladders, such as the one the decedent had separated, may not have the latest adjustable 

safety foot. Ladder safety feet increase the ladder’s “grip” on the ground and are found on 

the newer versions of extension ladders. 

Many organizations have published and/or posted on the Internet safe ladder use 

practices. The decedent’s actual work practices, except for separating the ladder, were 

unknown. Based on the activity, several additional work practices that may have 

contributed to this tragic incident are identified in the table below. 

Ladder placement against the 

heifer barn may not have been the 

appropriate pitch. 

A portable ladder’s safest pitch is when the 

horizontal projected distance from the top support 

to the base is not more than 1/4 of the vertical 

distance between these points. The more outward 

the base is moved from this position, the greater 

the risk that the ladder will slip outward and fall. 

When the base of the ladder is closer to a straight 

up and down position and used at a steeper angle, 

the ladder is at risk of toppling backwards when 

the worker leans away from it or losing its grip on 

the ground. 

The ladder did not have safety feet 

nor was the ladder secured. 

Safety feet and securing a ladder provides 

stability by minimizing ladder movement. The 

force exerted by the decedent as he was drilling 

the pilot holes may have put a side load on the 

ladder, causing the ladder to slip/move because 

the base (feet) end was not flush with the 

concrete. 

Ladder placement not against 

heifer pen building beam. 

To enhance safety, in addition to a properly 

angled ladder, four-point contact should be 

maintained. It is unknown if the decedent placed 

the ladder against the building beam. If he did not, 

then there would not be the necessary four-point 

contact with the working surfaces and this could 

have contributed to the ladder kicking out. 

Maintaining three-point contact 

with the ladder. 

Safe ladder use requires a worker to maintain a 

three-point connection (two hands/one foot or two 

feet/one hand) and his/her shoulders within the side 

rails. He may have had to use two hands to control 

the drill. 

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• Clear unrestrained animals from work areas prior to beginning work. 

Although the cattle were accustomed to the decedent’s presence in the herd, the decedent 

was performing a work activity that was “new” to the animals. He was on a ladder and 

using a drill that made a sound with which they may not have been familiar. Animals 

roaming in the area of the ladder provided an additional distraction to the decedent as he 

attempted to drill the pilot holes. The weight of the animals could easily move or dislodge 

a ladder from its position, causing the decedent to lose his balance and fall. To ensure 

safety of both the animal and human, unrestrained animals should be moved to another 

area or restricted from the work area. 

• When using fasteners like nails or screws, drill appropriately sized pilot holes and 

use appropriately sized fasteners. 

Figure 2 shows that nails were used to secure the fence lumber to the post. Nails offer 

shearing strength however drilling the wrong pilot size hole could allow easier nail 

withdrawal and less security than screws of the appropriate size and length. In hardwood 

lumber, correctly sized pilot holes are usually recommended prior to any nail or screw. 

Construction deck screws as well as nails could have been used by the decedent to 

reinforce the fence connection to the support post. When deciding on which nail to use, 

remember that a nail’s strength is based on its length and its diameter. Given the proper 

length, the nail can be driven far enough into the supporting member so the nail has its 

maximum allowable lateral strength. The strength of a properly placed nail is also 

dependent on its diameter as this affects the quantity of wood fibers that can bear against 

its surface. The "wider" the nail (greater diameter), the more wood fibers can bear, the 

stronger the connection. The nail length selected should be approximately three times the 

thickness of the board. A nail driven perpendicular to the grain should penetrate the 

lumber a minimum of 12 times its diameter. Building codes often call for at least half the 

length of the nail. 

Note that the type of nail (for example, box, common, cooler, gypboard) determines its 

diameter (diam). Therefore, choosing the proper type of nail for the application required 

is necessary. The nominal size of a 2x4 is 11⁄2 inches. #20d box and common nails are 

both 4 inches long and each would penetrate the post approximately 2.0 inches. There is 

quite a difference in their connection strength because the common nail had a greater 

diameter. 

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Nail Specifications (Units in inches)

Box Length Diam. Common Length Diam. Cooler Length Diam. Gypboard Length Diam. 

2d 1 0.067 2d 2d 1 0.062 2d 

3d 1.25 0.076 3d 3d 1.125 0.067 3.25d 1.1875 0.080 

4d 1.5 0.080 4d 4d 1.375 0.080 4d 1.375 0.080 

5d 1.75 0.080 5d 5d 1.625 0.086 5d 1.625 0.086 

6d 2 0.099 6d 2 0.113 6d 1.875 0.092 6d 1.875 0.0915 

7d 2.25 0.099 7d 7d 2.125 0.099 7d 2.125 0.099 

8d 2.5 0.113 8d 2.5 0.131 8d 2.375 0.113 8d 2.375 0.113 

9d 2.75 0.113 9d 9d 2.625 0.113 9d 

10d 3 0.128 10d 3 0.148 10d 2.875 0.120 10d 

12d 3.25 0.128 12d 3.25 0.148 12d 12d 

16d 3.5 0.135 16d 3.5 0.162 16d 16d 

20d 4 0.148 20d 4 0.192 20d 20d 

• Ensure emergency response can be summoned on a timely basis. 

The decedent’s wife had difficulty contacting emergency response based on her location. 

Farm owners should ensure that, if using cell phones for communication that the phones 

work on all areas of their farm. If the cell phone does not work at all work areas, then 

other communication options, such as walkie-talkies should be explored. 

RESOURCES 

MIOSHA standards cited in this report may be found at and downloaded from the 

MIOSHA, Michigan Department of Licensing and Regulatory Affairs (LARA) website 

at: www.michigan.gov/mioshastandards. MIOSHA standards are available for a fee by 

writing to: Michigan Department of Licensing and Regulatory Affairs, MIOSHA 

Standards Section, P.O. Box 30643, Lansing, Michigan 48909-8143 or calling (517) 322-

1845. 

• MIOSHA Construction Safety Standard, Part 11, Fixed and Portable Ladders 

• MIFACE Investigation Report #07MI007: Subject: Carpenter Dies After Fall 

From a Ladder That Slipped From Its Base While Positioned on Frozen Sand 

http://www.oem.msu.edu/MiFace/07MI007.pdf 

• WeatherUnderground data for the incident location and day. 

http://www.wunderground.com/ 

• MIFACE Investigation Report: #07MI136: Subject: Hotel Assistant Manager 

Dies Due to a Fall from a Ladder During Installation of Wood Trim 

http://www.oem.msu.edu/MiFace/07MI136.pdf 

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• MIFACE Investigation Report: #07MI122: Subject: Farmer Killed When He 

Became Entangled in Implement Drive Line/Posthole Auger 

http://www.oem.msu.edu/MiFace/07MI122.pdf 

• Nail Size Chart – Engineers Edge. 

http://www.engineersedge.com/nail_size_chart.htm 

• Nails. http://www.sizes.com/tools/nails.htm 

• The Right Nail for the Job. http://www.mcvicker.com/offtech/smnail.htm 

• Wikipedia - Ladders. http://en.wikipedia.org/wiki/Ladders 

KEY WORDS: Fall, ladder, cattle, farmer, agriculture 

MIFACE (Michigan Fatality Assessment and Control Evaluation), Michigan State 

University (MSU) Occupational & Environmental Medicine, 117 West Fee Hall, East 

Lansing, Michigan 48824-1315; http://www.oem.msu.edu. This information is for 

educational purposes only. This MIFACE report becomes public property upon 

publication and may be printed verbatim with credit to MSU. Reprinting cannot be used 

to endorse or advertise a commercial product or company. All rights reserved. MSU is an 

affirmative-action, equal opportunity institution. 9/13/11