MIFACE Investigation Report: #10MI075 

Subject: Farmer Run Over By Tractor During Idle Adjustment 

Summary 

In the Summer of 2010, a male farmer 

in his 40s died when he was run over 

by a John Deer 4430 tractor to which 

he was adjusting the idle. The decedent 

was working in a barn; the north wall 

of the barn faced the road and the south 

wall faced a large cornfield. The tractor 

was facing south. The throttle and gear 

shift controls were both located on the 

right side of the tractor. When the 

operator was in the driver’s seat, the 

operator pushed the throttle lever 

forward (away from the driver) and the 

gear lever backwards (toward the 

driver). Both levers were accessible 

while standing on the ground, and the 

lever activation reversed. The decedent was standing on the ground facing the tractor on 

the tractor’s right side, which placed the engine area in front of him with the small front 

tire to his right and the large right rear tire to his left. It appears that he reached up and in 

an attempt to activate the throttle (pulling it toward him) he contacted the gear shift lever, 

pushing it back which placed the tractor into gear. Because the tractor engine was 

operating at a high rpm, when placed into gear, the tractor went forward at a high rate of 

speed. The rear tractor tires left spin marks on the concrete floor of the barn. The tractor 

continued out the south barn door and arced to the north, crossing the road and continuing 

into a field. The tractor continued its arced path of travel through the field, and then 

passed between two houses, crossed a north-south road, and finally came to rest against a 

tree approximately one-third of a mile from the barn. Several of the decedent’s family 

members saw the tractor traveling without the operator and investigated. Seeing the 

decedent on the floor, they went to the house and notified another family member, who 

investigated and called for emergency response. Emergency response arrived and 

declared the decedent dead at the scene. 

RECOMMENDATIONS 

• Engage the tractor parking brakes and block tractor movement if tractor 

maintenance must be performed with the engine running. 

• Have a trained mechanic inspect used equipment prior to use to ensure equipment 

has all safety features intact and to note any equipment modifications that may 

affect equipment performance and function. 

Figure 1. Position of decedent standing in 

front of rear right tractor wheel 

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• Buyers of used tractors should ask the current owners if they bypassed or 

removed any safety switches on the tractor that is for sale. 

• Develop and implement a farm safety plan. 

• Routinely inspect tractors to identify potential safety issues, such as old/faded 

SMV emblems, missing PTO master shield, and roll-over protective structure 

(ROPS) availability. Install/re-install missing or damaged items. 

• Manufacturers should review with their dealer network trends related to the 

disconnection, alteration, removal or failure of safety devices to determine 

possible reasons that may lead to redesign, safety notices, operator’s manual notes 

or other actions. 

INTRODUCTION 

MIFACE personnel were notified of this incident by a newspaper clipping. MIFACE 

contacted the decedent’s family and they agreed to participate in the MIFACE research 

program. MIFACE conducted a site visit in November 2010. During the writing of this 

report, the police report and pictures, death certificate and medical examiner’s report was 

reviewed. The family permitted MIFACE to take pictures of the incident site and the 

tractor involved in the incident which was stored in a remote location. 

The decedent was born and raised on a farm and began running his own farm operation 

after finishing high school. He bought the farm where the incident occurred in 2007. He 

farmed approximately 3000 acres (corn, soybeans and wheat). 

The decedent employed five individuals. The family indicated that employee safety 

training was provided, but not documented. The decedent provided verbal safety training 

and correction of unsafe behavior to his employees. No documentation of the provided 

safety training and correction was maintained. The decedent required employees to 

demonstrate that they had the skill level to perform a task prior to their assignment to the 

task. The decedent’s work hours were based on season. On the day of the incident, he had 

already worked five to eight hours. 

The decedent bought the John Deere 4430 tractor at an auction approximately five 

months prior to his death. The John Deere had 8 forward gears and 2 reverse gears. There 

were 3937 hours on the gauge. At the time of the incident, the tractor was used for both 

traditional farming tasks as well as for tractor pulls. Since purchasing the tractor, the 

decedent had made some modifications to it so it could be used in tractor pulls, such as 

switching the hitch, cutting off the draw bar, and adjusting the fuel injector pump to gain 

horsepower. The decedent had purchased several of the required safety stickers for the 

tractor, such as the shift pattern sticker and sticker indicating no starting the tractor on the 

ground. 

His family members indicated that the decedent recognized there was a problem with the 

tractor when he purchased it; the tractor did not start on a consistent basis and had stalled 

when used in tractor pulls. At the time of the incident, the tractor was not equipped with 

any attachments. 

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North door 

South door 

Direction 

tractor 

was facing 

Figure 2. Overview of incident scene. 

INVESTIGATION 

The barn in which the decedent 

and tractor were located was on the 

southwest corner of a road. There 

were two large entrance doors on 

the barn; one on the north wall and 

one on the south wall. The barn 

floor was concrete (Figure 2). 

The decedent and a coworker had 

been working at another farm 

location owned by the decedent. 

They returned to the incident scene

and made a list of items needed.

When the coworker departed, the 

decedent was working alone in the 

barn on the tractor involved in the 

incident, increasing its idle and 

RPM. The coworker stated at the 

time of his departure, the tractor 

was facing north. 

At some point after the coworker 

departed, the decedent moved the 

tractor so it was facing south. The 

tractor was running while the 

decedent was adjusting the idle 

with a 10 mm wrench (Figure 3). 

Based on the decedent’s resting 

position, marks on his clothing and 

injuries sustained, the decedent 

position could be ascertained. He 

was standing on the ground facing 

the tractor on the tractor’s right 

side, which placed the engine area 

in front of him with the small front 

tire to his right and the large right 

rear tire to his left (Figure 1). 

The throttle and gear shift controls 

were both located on the right side 

of the tractor. A driver seated in 

the operator seat would push (away 

from the operator) the throttle lever 

to control engine speed. To specify 

Figure 3. Police re-enactment of work decedent 

was performing. 

Gear Shift 

Throttle 

Figure 4. Gear shift and throttle identified. 

Picture taken from operator’s seat. 

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the tractor’s gear level, the operator pulled the gear lever backward toward the driver. 

From the position where the decedent was working on the tractor it would be possible for 

him to access both levers from the ground. Because the decedent was standing on the 

ground facing the tractor, the activation direction of the levers was reversed – the throttle 

lever activation would be toward him and the gear shift lever activation away from him. 

The throttle is identified by a red, cylindrical handle and the gear shift has a yellow, 

round ball handle (Figure 4). 

It is unknown if the tractor was in Park or 

Neutral. It appears that he reached up to 

activate the throttle. As he reached to pull the 

throttle back toward him, he faced the right 

rear tire (Figure 1). Given the configuration of 

the tractor, he would have been pressed 

against the rear tire when reaching up to the 

controls. At some point, he contacted the gear 

shift lever, pushing it back thus placing the 

tractor into gear. Because the tractor engine 

was operating at a high state of idle, the clutch 

would not need to be depressed to place the 

tractor in gear. When the tractor was placed 

into gear, it lurched forward at a high rate of 

speed leaving spin marks on the barn’s 

concrete floor. 

Figure 5. “Spin” marks left by the 

tractor’s rear right wheel 

Figure 7. Path of tractor across 

north/south road and into/out of field 

Tire tracks on the floor led out the south door Figure 6. Path of tractor out the south and the tractor began drifting to the door and arcing into field southwest into a cornfield, and then arced to 

the north, crossing the road (north barn door faced this road) and continued into the field 

across from the barn. The tractor continued its arced path of travel through this field, and 

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then passed between two houses, crossed a north-south road, and finally came to rest 

against a tree approximately one-third of a mile from the barn (Figures 6 and 7). 

A member of the decedent’s family saw the tractor leaving the barn without an operator 

and ran to the house to get another family member. The family members returned to the 

incident scene. Seeing the decedent on the floor, they went back to the house and notified 

another family member, who went to the barn. Seeing the decedent lying on his back on 

the floor, the family member called for emergency response. 

Emergency response arrived and declared the decedent dead at the scene. The responding 

police found a 10mm wrench on his shoulder. 

The decedent’s father found the tractor stalled in the roadway still in gear prior to being 

notified of the accident. He parked the tractor on the shoulder of the roadway and went to 

the farm. 

After the incident, the family had the tractor inspected by a mechanic. The mechanic 

found that the neutral safety switch had been bypassed by the previous owner. According 

to the family, the decedent was unaware of this safety bypass. 

CAUSE OF DEATH 

The cause of death as stated on the death certificate was craniocerebral trauma. 

Toxicological tests indicated no alcohol, prescription or illegal drugs in his blood. 

RECOMMENDATIONS/DISCUSSION 

• Engage the tractor parking brakes and block tractor movement if tractor 

maintenance must be performed with the engine running. 

When performing tractor maintenance with the engine running, safe work practice should 

include setting the tractor parking brakes and block potential tractor movement. To block 

the tractor movement, two options include: (1) chocking the wheels or (2) raising the 

back axle and placing the axle on substantial blocking high enough so the rear tires are 

suspended. Chocking can prevent accidental or unintended equipment movement by 

providing a physical stopper to the wheels. MIFACE recommends the use of wheel 

chocks of the appropriate size and material to securely hold the tractor based upon the 

tractor tire size and weight. Most chocks have the manufacturer’s recommended tire size 

identified on the chock. MIFACE found chock suppliers on the internet that had chocks 

available for 8-foot tall tires for mining trucks. MIFACE recommends placing a chock 

against all of the tractor’s wheels. 

MIFACE does not recommend the use of lumber, cinder blocks, rocks, or other makeshift items to chock a tire. 

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• Have a trained mechanic inspect used equipment prior to use to ensure equipment 

has all safety features intact and to note any equipment modifications that may 

affect equipment performance and function. 

The decedent bought the tractor at an auction without an inspection. He recognized there 

was a problem with the tractor, but did not have a qualified individual conduct a safety 

check/inspection to pinpoint the problem. After the incident, a mechanic found that the 

neutral safety switch was bypassed, thus allowing the engine to be started while the 

transmission was in gear, instead of allowing the engine to be started only when the 

transmission was in neutral or park. Prior to using a newly purchased piece of used 

equipment, MIFACE recommends that the owner have the equipment inspected by a 

qualified mechanic or dealership mechanic and repaired as required. 

• Buyers of used tractors should ask the current owners if they bypassed or 

removed any safety switches on the tractor that is for sale. 

Sellers of used equipment, including tractors, usually sell the equipment in an “as is” 

condition. Buying from a name brand dealer adds some possibility that a safety check of 

all safety switches on that specific tractor was performed, especially if it is the brand of 

used tractor sold and serviced by the selling dealer. 

Ideally, sellers should have the equipment inspected by a qualified individual and/or 

provide a detailed equipment report to the buyer identifying the equipment’s condition, 

such as equipment modifications and repairs needed. The seller should provide this 

information to the prospective buyer prior to purchase. Buyers could utilize a simple 

checklist such as the one developed below to ask the sellers some basic information about 

the tractor prior to purchase: 

Brand 

Model 

Serial # 

Circle one If Yes, Specify 

Was this tractor modified during your 

ownership? 

Y/ N/ NA 

Specific parts removed and not replaced? Y/ N/ NA 

Disabled or removed safety switches or 

safety features? 

Y/ N/ NA 

Any non-mfg parts or after market 

attachments? 

Y/ N/ NA 

Any defects or needed repairs that you 

are aware of? 

Y/ N/ NA 

If Dealership sale, any repairs performed 

prior to sale? 

Y/ N/ NA 

Any other items I should be aware of? Y/ N/ NA 

Name, Address, Phone number of current 

owner 

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• Develop and implement a farm safety plan. 

There are no legal requirements in Michigan for a written safety plan in agricultural 

industries. We recommend a written safety plan. This plan will identify the safety and 

health hazards for the farm, so hazard controls can be developed. A safety plan, that is 

communicated to all who work on the farm will help raise awareness of safety issues, 

promote safe work practices, and have additional benefits of increasing work efficiency, 

and minimizing costs (a written safety plan may reduce worker compensation premiums). 

A safety plan should include work rules, such as safe tractor operation and signage. 

MIOSHA has many resources, including standard guidance, sample plans for safety and 

health issues such as respirator use, and training material handouts. Michigan Farm 

Bureau, with funding from the MIOSHA Consultation, Education and Training (CET) 

Division grant has developed a sample farm emergency preparedness safety plan as well 

as checklists for farm hazards. The information can be accessed at 

http://www.michfb.com/safety. 

• Routinely inspect tractors to identify 

potential safety issues, such as old/faded 

SMV emblems, missing PTO master shield, 

and roll-over protective structure (ROPS) 

availability. Install/re-install missing or 

damaged items. 

Figure 8 shows the unguarded PTO stub, faded 

SMV emblem, and lack of a ROPS on the 

decedent’s tractor. Although the lack of and/or 

condition of these safety features were not a factor 

in this incident, tractor owners should ensure that 

shields are re-installed, faded SMV emblems are 

replaced, and determine if a tractor can be 

retrofitted with a ROPS. 

• Manufacturers should review with their dealer network trends related to the 

disconnection, alteration, removal or failure of safety devices to determine 

possible reasons that may lead to redesign, safety notices, operator’s manual notes 

or other actions. 

Tractor owners do and will continue to modify tractors to meet the individual owner’s 

operational requirements. Manufacturers can minimize the risk to these owners by 

continuing to implement industry consensus standards related to safety features and 

typical post production equipment adaptations. Reviewing a trend of disabling or 

removal of particular safety equipment may provide the manufacturer with an 

understanding of the issues that led to the modification or removal. Future designs 

should consider these issues to maximize the full use of safety features. Operator’s 

Figure 8. Incident tractor 

showing lack of PTO master 

shield and ROPS and faded 

SMV. 

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manuals and training materials should continue to stress the importance of safe operating 

and maintenance procedures. 

RESOURCES 

MIOSHA standards 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. 

• Power Take-Off (PTO) Safety, Murphy, Dennis J. National Ag Safety Database. 

http://nasdonline.org/document/905/d000745/power-take-off-pto-safety.html 

Key Words: Pulling tractor, Tractor Runover, Idle Adjustment, Machine, 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. 

 10/31/2011 

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