MIFACE INVESTIGATION REPORT: #10MI067 

Subject: Volunteer Mowing Grass Pinned by Overturned Tractor 

Summary 

In the Summer of 2010, a male 

volunteer in his 70s was killed 

while mowing grass for a youth 

organization's camp using a 

tricycle-type Allis Chalmers 

Model L59AC farm tractor, 

retrofitted with an after-market, 

home-installed underbelly power 

rotary mower attachment. The 

tractor overturned to the side on 

an approximately 30-degree hill 

and pinned him beneath it. The 

tractor was not equipped with a 

rollover protection structure 

(ROPS) and seat belt (Figure 1). 

The decedent had mowed the 

property for over 30 years. The 

following scenario has been 

developed since his death was not witnessed. The decedent arrived at the camp and drove 

the tractor to the top of the hill behind the building. Starting from the tip of the hill, he 

drove the tractor downhill between the two trees and then turned north toward the bottom 

stairs leading to the building. He then ascended the 30-degree hill and as he was turning 

the tractor southbound at the top of the hill, the outside wheel lost its traction and the 

tractor overturned to the side. His tractor, according to his family members was in first 

gear. His tractor speed was unknown. A neighbor found him pinned under the overturned 

tractor’s seat. The neighbor ran to the nearest residence where emergency response was 

called. The homeowner and neighbor ran back to the incident scene and attempted to 

render aid. The fire department arrived, removed the tractor from the decedent, and 

performed resuscitative measures. He was pronounced dead at the scene. 

RECOMMENDATIONS 

• When cutting lawn grass on a slope, use a rollover protective structure (ROPS) 

equipped riding mower or agricultural tractor. 

• Vintage tractor owners should determine if their vintage tractors can be retrofitted 

with an approved ROPS and seat belt and do so if a ROPS is available. 

• Tractor owners, and especially vintage tractor owners, need to be sure that the 

modification of their tractor with non-original manufacturer’s attachments does 

not increase injury risk to the operator. 

N 

Figure 1. Overview of incident scene showing 

mowing path and position of decedent on hill. 

Tractor had been removed from decedent by 

emergency response. 

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• Service organizations should develop a comprehensive safety and health program 

or safety management system that addresses management leadership and 

worker/volunteer involvement. As part of the safety and health program, the 

organization should conduct a hazard assessment of the workplace and 

volunteers/employee training. 

• Develop and post Rules of Mowing on the organization’s grounds. The Rules 

should include two specific increased hazard situations: 1. Mowing on slopes and 

hills and 2. Mowing near the edge of lakes, ponds and dry gullies. 

• Convert tricycle-configured tractors to a wide front-end configuration. 

• Ensure any implement of husbandry, such as a tractor, when used on a public 

roadway has a slow moving vehicle sign. 

INTRODUCTION 

MIFACE personnel were notified of this incident by a Michigan State University 

Extension agent. MIFACE contacted the decedent’s spouse and was granted permission 

to conduct a site visit on October 1, 2010. With the decedent’s spouse was the decedent’s 

son-in-law, who also provided information during the MIFACE interview. The police 

report, medical examiner case report, and the death certificate were reviewed. The 

decedent’s son-in-law accompanied the MIFACE investigator to the incident site and 

explained a likely scenario of events. The picture used in Figure 1 is courtesy of the 

responding police department. The picture used in Figure 2 and the video were taken by 

the MIFACE investigator at the time of the site visit. The picture used in Figure 3 is 

courtesy of John Deere’s Farm & Ranch Safety Management Manual (Figure 45, page 

162). The picture used in Figure 4 is courtesy of Pennsylvania State University. The 

picture used in Figure 5 is courtesy of Farm Safe Vermont 

(http://farmsafevt.wordpress.com/page/4/?pages-list). 

The decedent grew up on a farm and was familiar with tractor operation and 

maintenance. He had back surgery in 2009. He was taking medications for his heart. 

INVESTIGATION 

The camp was located at the end of a 

road on the east side of a cul-de-sac. 

The camp building was five feet away 

from the nearest tree. There was 16 feet 

6 inches between the two trees shown 

in Figure 2. The ground was fairly 

level approximately 16 feet from the 

building and then the slope of the hill 

commenced. The hill undulates and 

there was a knoll approximately 10 to 

12 feet from the edge of the road. The 

decedent had mowed this property for 

over 30 years. 

Figure 2. At top of hill, facing north looking 

through two trees near the building. 

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A 360-degree view of the camp property he was mowing can be seen here. 

The responding police identified the tractor as an Allis Chalmers Model L59AC farm 

tractor in a tricycle configuration. The tractor had been modified the tractor to mow grass 

by attaching a powered rotary mower under the body of the tractor. The mower was 

raised and lowered by a hand lever and chain that he utilized while sitting in the tractor 

seat. He had been mowing the camp property the morning of the incident day. According 

to his family, a bolt on the mower came loose when he struck something, so he returned 

home and replaced the bolt. He ate lunch and then returned to the property at 

approximately 2:50 p.m. At approximately 3:00 p.m., the decedent exchanged greetings 

with a neighbor and his family who were on a walk as he was driving the tractor back to 

the camp property. 

Using the police photos indicating the pattern of the mowed grass, the following scenario 

has been developed. The decedent arrived at the camp and drove the tractor to the top of 

the hill behind the building. Starting from the top of the hill, he drove the tractor downhill 

between the two trees and then turned north toward the bottom stairs leading to the 

building. He then ascended the 30-degree hill and as he was turning the tractor 

southbound at the top of the hill, the outside wheel lost its traction and the tractor 

overturned to the side (Figure 2). His tractor, according to his family members was in 

first gear. His tractor speed was unknown. 

Several minutes later, the neighbor’s family arrived at the cul-de-sac. The neighbor saw 

the overturned tractor and told his family to remain where they were and he would 

investigate. The neighbor approached the overturned tractor and yelled to the decedent. 

Upon arriving at the incident scene, he observed that the decedent was “blue”. He 

returned to his family member and advised that they needed to get help. They then ran to 

the nearest house and called for emergency response. 

The home owner and neighbor who found the decedent ran back to the scene to see if 

they could render help. When they arrived back at the decedent’s location, the decedent 

did not have a pulse. 

The decedent was found face down on the side of the hill with the tractor seat pinning his 

right shoulder blade to the ground. His head was pointed in a northern direction and the 

nose of the tractor was pointed in a southeastern direction (tractor direction as shown in 

Figure 1). Emergency response arrived and rendered aid. The decedent was declared dead 

at the scene. 

CAUSE OF DEATH 

The cause of death as stated on the death certificate was traumatic asphyxia. Toxicology 

was negative for alcohol, prescription or illegal drugs. 

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RECOMMENDATIONS/DISCUSSION 

• When cutting lawn grass on a slope, use a rollover protective structure 

(ROPS)/seatbelt equipped riding mower or agricultural tractor. The operator 

should use the seatbelt. 

The lower center of gravity of a riding mower may increase stability on a slope compared 

to an agricultural tractor which has a higher center of gravity. Both the lawn tractor and 

agricultural tractor should be equipped a ROPS/seatbelt. Many riding mowers/lawn 

tractors have a foldable ROPS and seat belt as standard equipment to keep the operator 

within the “zone of protection” (See Figure 3). The foldable nature of the ROPS 

facilitates mowing under low-hanging obstacles and in storing of the mower/tractor. 

• Vintage tractor owners should determine if their vintage tractors can be retrofitted 

with an approved ROPS and seat belt and do so if a ROPS is available. 

Some, but not all, older vintage tractors can be retrofitted with ROPS. Some tractors 

cannot be retrofitted with a ROPS/seatbelt according to the manufacturer or the cost of 

the retrofit is excessive in relation to the value of the tractor. In these cases, MIFACE 

recommends that the operators discontinue the use of the non-ROPS/seatbelt-equipped 

tractor. 

Tractor rollovers are likely to occur on hilly terrain 

when the center of gravity on the tractor becomes 

unbalanced. The field slope, tractor speed, turning 

radius, rear axle torque and center of gravity are all 

interrelated factors that impact the stability of a 

tractor. ROPS are designed to help limit a tractor 

overturn to 90 degrees and to provide the operator a 

“zone of protection” (Figure 3). The operator stays 

within this zone only if they also wear the seat belt. 

The operator will not be protected by the ROPS 

during an overturn if the operator is not wearing a 

seatbelt since the operator may be totally or partially thrown off the tractor. Even inside a 

cab, seat belts are important to keep the operator from being thrown against the frame, 

through a window, or out a door. Therefore, when an older tractor is retrofitted with a 

ROPS, approved seatbelts must also be installed. Seat belts may not be included with an 

available ROPS package and will have to be purchased separately. 

The University of Kentucky’s College of Agriculture maintains a Web guide “The 

Kentucky ROPS Guide” to ROPS tractor retrofits 

(http://warehouse.ca.uky.edu/rops/ropshome.asp). The ROPS listed in the guide are 

organized by tractor make and model. Another option for owners of older tractors to 

obtain information about ROPS retrofits is to contact their local extension office or 

tractor dealership. ROPS should be certified to meet at a minimum the standards and 

Figure 3. ROPS/Seatbelt 

providing zone of protection 

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regulations of various agencies that ensure that the frame or enclosure is designed to 

provide overturn protection. 

http://weblogs.nal.usda.gov/infofarm/farm_safety/index.shtml 

Seat belts should not be used on tractors that do not have a ROPS. Additionally, ROPS 

should not be manufactured in the farm machine shop. OSHA requires that ROPS are 

labeled/marked, therefore, tractor owners should look for a label on the frame or 

enclosure stating it meets rollover protection standards. 

• Tractor owners, and especially vintage tractor owners, need to be sure that the 

modification of their tractor with non-original manufacturer’s attachments does 

not increase injury risk to the operator. 

Due to the high center of gravity of some vintage tractors, custom or modifying nonoriginal manufacturer’s attachments to fit could be a misapplication of the intent of the 

original tractor’s use. Aftermarket attachments for agricultural equipment are common on 

some models of older agricultural tractors. Although the weight of the belly mower may 

help to stabilize this tractor, operators need to review the owner’s manual for proper 

attachment to the specific tractor and user techniques. Engineering factors unknown to 

the modifiers may add risk to any user of such equipment. 

• Service organizations should develop a comprehensive safety and health program 

or safety management system that addresses management leadership and 

worker/volunteer involvement. As part of the safety and health program, the 

organization should conduct a hazard assessment of the workplace and 

volunteers/employee training. 

The service organization relied on the pre-existing safety knowledge of the decedent. The 

difficulty in relying on the experience a volunteer brings to a task is that the volunteer 

may use unsuitable equipment, have developed unsafe work practices, become 

comfortable or complacent, or be using their work skills in a new setting and be 

unfamiliar with hazards of new tasks. 

MIFACE recommends that the organization develop a comprehensive safety and health 

program, or safety management system that addresses management leadership and 

volunteer involvement and conduct a workplace analysis including hazard assessment. 

The hazard assessment will provide information to develop hazard prevention and control 

strategies and volunteer (and paid staff if indicated) safety and health training and 

education. A hazard assessment may have identified the slope of the hill as a safety issue. 

Any organization should review the risks of permitting workers/volunteers to use nonROPS equipped equipment, such as tractors or riding lawn mowers due to rollover and 

stability issues 

The service organization should develop safe work practices and procedures to reflect the 

nature of their unique working environment and job tasks. With the assistance of their 

volunteers, the organization should evaluate tasks performed, identify all potential 

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hazards, and then develop, implement, and enforce safe work procedures, conduct 

necessary training, and periodically evaluate the effectiveness of the hazard mitigation 

addressed by the procedures. Additionally, the organization could set policy regarding 

training, health and/or vision requirements of volunteer labor, as well as age limitations 

for equipment operators. 

In this incident, the decedent was performing what was considered groundskeeping 

duties. The MIOSHA General Industry Safety Standard, Powered Groundskeeping 

Equipment, Part 54 would apply and should be used to ensure that groundskeeping work 

is performed safely. Rule 5443(4) of Part 54 states: “Riding groundskeeping equipment 

shall not be operated up or down a slope of more than 26 degrees or move across the face 

of a slope of more than 17 degrees. In addition, Rule 5443 (5) states that “a deviation 

from the requirements of subrule (4) may be obtained from the department of labor by 

presenting special design or modification criteria which shows an ability to perform 

safely on a specific slope of a greater degree without slipping or tipping. 

Although the tractor may have been suitable for mowing the level area in back of the 

lodge, it was unsuitable for mowing the hill. Utilizing a ROPS-equipped riding lawn 

mower may have been a more suitable piece of equipment for that job task. 

MIOSHA health and safety standards as well as best industry practices can be utilized to 

support this effort. MIOSHA Consultation, Education and Training Division has many 

resources for an organization to use and adapt to their needs. The Non-Profit Risk 

Management Center (http://www.nonprofitrisk.org/) has an online tutorial and an online 

safety and health toolkit to assist non-profit organizations in the development and 

implementation of a health and safety program. 

• Develop and post Rules of Mowing on the organization’s grounds. The Rules 

should include two specific increased hazard situations: 1. Mowing on slopes and 

hills and, 2. Mowing near the edge of lakes, ponds and dry gullies. 

There are a number of websites that highlight the safety issues involved when using 

riding lawn mowers. For example: 

 West Virginia University Extension Service: 

http://safetyandhealth.ext.wvu.edu/r/download/22008 

 Exmark: http://www.exmark.com/pdfs/SafetyTips.pdf 

 Kansas State University Extension: 

http://www.ksre.ksu.edu/library/ageng2/mf2714.pdf 

The information contained on these and other websites can be used by any organization 

to develop Rules of Mowing to ensure the operator understands the safety issues inherent 

in using the mower. 

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• Owners using tricycle-configured tractors should convert them to a wide front-end 

configuration. 

The victim was using a vintage tricycle-configured tractor. Tricycle-configured tractors, 

with the narrow-front wheel design are inherently less stable than tractors with a widewheel configuration. Tricycle tractors also have stability baselines which leave little room 

for error (Figure 4). The stability baseline of a tractor is made up of imaginary lines 

drawn between the points where the tractor tires contact the ground. Front, rear, and side 

stability baselines are established. To avoid turnover, the center of gravity must stay 

within the tractor's stability baseline. The tractor's center of gravity does not move, but its 

relationship with stability baselines may change due to: 

 Added weight from attachments and items being hauled (center of gravity will 

shift to the front or rear of the tractor depending on what is attached or is being 

hauled), 

 Driving on a slope (center of gravity shifts to the downhill side), 

 Lifting a load (center of gravity shifts towards the load), 

 Turning too fast (center of gravity shifts to the opposite direction you are turning 

in). 

A tractor's center of gravity is the point 

where all parts balance one another. On a 

two-wheel drive tractor on level ground, 

the center of gravity is typically 10 inches 

above and two feet in front of the rear axle 

(in the center), which is about where the 

operator's feet are located. The center of 

gravity on a four-wheel drive and centerarticulating tractor is located slightly more 

towards the front of the tractor. 

Converting a tricycle tractor to a wide-front configuration and setting the wheel tread at 

the widest setting suitable for the task will provide the widest possible base of stability. 

This should also be done in a manner that doesn’t create a bigger hazard. Use approved 

retrofits only. 

• Ensure any implement of husbandry, such as a tractor, when used on a public 

roadway has a slow moving vehicle sign. 

Although not a factor in this incident, the decedent’s tractor was operated on a public 

roadway and thus should have been equipped with a slow moving vehicle (SMV) 

emblem. The Michigan Motor Vehicle Code holds the tractor driver “at fault” if another 

vehicle rear-ends a tractor without a SMV emblem. 

A SMV emblem is a reflective orange triangle bordered with red that warns other road 

users that the vehicle displaying the sign is traveling slower than the normal speed of 

traffic. The American Society of Agricultural Engineers (ASAE) has developed new 

Figure 4. Stability baselines for tricycle 

and wide-front tractors 

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recommendations for lighting and marking equipment (ASAE S276.6, January 2005). 

Although the SMV emblems meeting the old ASAE 

standard are still available, MIFACE encourages 

owners of implements of husbandry operated on the 

roadways to purchase SMV emblems meeting the 

new recommendations. SMV emblems meeting the 

recommendations in ASAE 276.6 are in packages 

labeled with S276.5 or a higher number. 

The new SMV emblems have fluorescent material 

aiding daytime visibility and reflective material 

aiding nighttime visibility (Figure 5). Replacing 

worn SMV emblems is important because the orange 

fluorescent center portion of the SMV emblem fades 

and turns color over time, changing from orange to 

yellow, pink or white. This portion is the most 

vulnerable to light and moisture degradation because 

fluorescent dyes decompose. 

Retro-reflective material as found in the outer border of the SMV emblem reflects the 

headlights of vehicles approaching from the rear at night. Retro-reflective material holds 

up longer than fluorescent material. The retro-reflective readings on SMV emblems 

meeting the new ASAE standard are over ten times greater than most of the readings on 

SMV emblems currently in use. Figure shows a comparison of older and newer SMV 

emblems. The SMV on the left is a new sign under the old standard, the SMV in the 

middle is a new sign under the new standard, and the SMV on the right is an old sign 

under the old standard. 

REFERENCES 

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

MIOSHA, Michigan Department of Licensing and Regulatory Affairs (MDLARA) 

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 General Industry Safety Standard, Part 54: Powered Groundskeeping 

Equipment 

• Farmer Dies when Tractor rolls over on sloped Terrain. Wisconsin FACE 

Program. 

http://www.dhs.wisconsin.gov/dph_boh/face/PDF/04WI019TractorRollover.pdf 

• Tractor Safety. Virginia Tech, Environmental Health and Safety. 

http://www.ehss.vt.edu/programs/FAR_tractor_safety.php 

• Tractor Stability. HOSTA Task Sheet 4.12. Hazardous Occupations Safety 

Training in Agriculture. National Safe Tractor and Machinery Operation Program. 

http://www.nstmop.psu.edu/tasksheets/4.12%20Tractor%20Stability.pdf 

Figure 5. Center SMV emblem 

equipped with ASAE 276.6 

recommendations 

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• Riding Lawn Mower Safety. West Virginia University Extension Service. 

http://safetyandhealth.ext.wvu.edu/r/download/22008 

• Mowing Safety Tips. Exmark. http://www.exmark.com/pdfs/SafetyTips.pdf 

• Mowing and Trimming Safety for the Landscaping and Horticultural Services 

Industry. Kansas State University Extension. 

http://www.ksre.ksu.edu/library/ageng2/mf2714.pdf 

Key Words: Tricycle tractor, Mowing Slope, Service Organizations, Powered Rotary 

Mower, Other Services 

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. 

 10/7/2011 

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