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MIFACE Investigation Report: #14MI118

Subject: Farm Worker Died When Unsupported Combine Head Fell Onto 

Him During Repair Activities in a Bean Field

Summary

In fall 2014, a male farm worker in his 30s died when the 

unsupported Case International 1680 combine soybean 

head lowered onto his side during repair activities in a 

soybean field. The decedent was working alone in the 

field harvesting soybeans. Although the incident was 

unwitnessed, it was hypothesized that the sensing 

mechanism, which permitted the hydraulically operated 

head to float over the ground became “stuck” in a raised 

position. The decedent exited the combine and left the 

combine running. He did not take the combine head out 

of “automatic” control. He went under the raised combine 

head with a crescent wrench without providing secondary 

support (header safety stop) to prevent the head from lowering when repairs were completed. 

Based on the above hypothesis, the decedent could have been: 1) attempting to make an 

adjustment directly to the combine head to lower it from the raised position or 2) was striking the 

floating sensing “rod” which was stuck in the raised position to free the head. When the combine 

head released from its raised position, it fell onto the decedent, pinning him on his side against 

the dirt. His coworkers went to look for him when he did not answer his cell phone. A coworker 

found him, raised the combine head, and backed the combine approximately 15 feet away from 

him (Figure 1). Combine hydraulic fluid was not observed on the ground, indicating that there 

was not a leak from the hydraulic lines. He was declared dead at the scene.

MIFACE identified the following key and possibly contributing factors:

 Working under unsupported raised combine head

 Did not turn off machine prior to dismounting 

 Washout area in field

RECOMMENDATIONS

 Always use cylinder locks when available to provide secondary support when working 

under an elevated combine head. If cylinder locks are not available, block the combine 

head with a material, which will not crush under the weight of the unit.

 Calibrate header for each harvest site, evaluate ground site conditions and adjust

harvesting procedures accordingly.

Figure 1. Combine and header involved 

in incident in field. 
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 Use appropriate equipment shut off procedures when dismounting the equipment.

 Combine manufacturers should install a safety interlock system, such as a seat safety 

switch for operator seats and offer retrofit seat safety switches.

BACKGROUND

In fall 2014, a male farm worker in his 30s died when the unsupported Case International 1680 

combine soybean head lowered onto his side during repair activities in a soybean field. 

MIFACE learned of this incident from the MIOSHA 24-hour hotline. The decedent’s employer

was contacted and agreed to a MIFACE site visit. The MIFACE researcher met with the owner

at the company’s main office. The owner traveled with the researcher to an offsite location to 

permit the researcher to take pictures of the combine head involved in the incident. During the 

course of this investigation, the death certificate and police and medical examiner reports and the 

MIOSHA compliance file were reviewed. Pictures used in this report are from the responding 

police department (Figure 1), MIOSHA compliance file (Figure 2) and the MIFACE site visit

(Figure 3). 

The company farmed 8000 acres in five counties harvesting a variety of products – corn, wheat, 

soybeans, oats, barley, etc. The firm also had a feed business (straw and hay to dairy), hauled

chicken waste, had beef cattle, and grew and distributed certified seeds for farms. 

The company representative who spoke with MIFACE indicated that the firm employed 20 

individuals and to the MIOSHA compliance officer, the firm representative indicated the 

company employed four individuals. The decedent was a family member and had his own farm. 

In addition to his farming operation, he had worked at this business full time for the past 17 

years. His work hours were a routine 8-hour day unless it was planting and harvesting season; 

hours would increase until the work was finished. The decedent was paid on an hourly basis.

For each new farm machine operator, the company owner demonstrated the operation of the 

machine and then rode with the new operator for a day to ensure operator competence. At the 

beginning of each season, the owner would review with employees the pertinent safety 

instructions for the machines they would operate and provide an opportunity for the employee to 

ask questions. Each year, he reviewed the importance of the hydraulic cylinder locks and had 

reviewed this issue with the decedent a few weeks prior to the incident. The owner did not keep 

training records. 

The decedent was very familiar with combine operation and had operated this combine for many 

years. 
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Firm Remediation

At the time of the incident, the business owner verbally communicated safety instructions. After 

the incident, the firm developed a written safety program, which included training record 

documentation.

MIOSHA General Industry Safety and Health Division issued a Serious and one Other-thanSerious citation at the conclusion of its investigation.

SERIOUS: 1928.57(a)(6)(iii): GI PART 53, FARM FIELD EQUIPMENT REF 408.45301

At the time of initial assignment and at least annually thereafter, shall instruct every 

employee in the safe operation and servicing of all covered equipment with which he is 

or will be involved, including at least the following safe operating practices:

Stop engine, disconnect the power sources, and wait for all machine movement to stop 

before servicing, adjusting, cleaning, or unclogging the equipment, except where the 

machine must be running to the property serviced or maintained, in which case the 

employer shall instruct employees as to all steps and procedures which are necessary to 

safely service or maintain the equipment.

(Employee did not stop or turn off equipment while trying to repair the Case International 

1680 combine.) 

OTHER-THAN-SERIOUS: 408.22139(1): GI PART 11, RECORDING AND REPORTING OF 

OCCUPATIONAL INJURIES AND ILLNESSES

Basic requirement. Within 8 hours after the death of any employee from a work-related 

incident or the inpatient hospitalization of 3 or more employees as a result of a workrelated incident, you must orally report the fatality/multiple hospitalization by telephone 

or in person to the Michigan Department of Consumer and Industry Services, Bureau of 

Safety and Regulation, State Secondary Complex, 7150 Harris Drive, Lansing, Michigan, 

phone 1-800-858-0397.

(Firm did not report fatality within 8 hours to MIOSHA.)

INVESTIGATION

Machine

The machine involved in the incident was a 1990 Case International combine, Model 1680. 

Attached to the combine was an approximately 30-foot long header with an automatic floating 

cutter, which allowed the head to raise and lower by sensing ground height while preventing the 

sickle guards from digging into the ground and picking up debris. The combine head had a 

control button that could be operated by the driver from inside of the cab. 
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On the day of the incident, the decedent worked in the shop and then in the afternoon, was one of 

four combine operators who traveled to their respective fields. This was the first day of 

combining; the previous week the decedent did not work because of weather issues. 

Three combines were in one field and the decedent was working alone in a nearby soybean field, 

out of visual distance from his coworkers. He was 

making his first pass. Rain had washed out an 8-10 inch 

deep portion of the field near a ditch. The combine head 

rammed this washout, causing the head to move upward

and stick in the raised position, approximately 4 feet 

above the ground. 

The decedent exited the combine and left the combine 

running. He did not take the combine head out of 

“automatic” control. He went under the raised combine 

head with a crescent wrench without providing secondary 

support (header safety stop) to prevent the head from 

lowering when repairs were completed. There was a pair 

of work gloves on the ground by his body along with a bungee-type strap. Although the event 

was unwitnessed, two hypotheses were developed: 1) 

He may have been attempting to make an adjustment 

directly to the combine head to lower it from the raised 

position (Figure 2) or 2) he was striking the floating 

sensing “rod” which was stuck in the raised position to 

free the head (Figure 3). When the combine head 

released from its raised position, it fell onto the 

decedent, pinning him on his side against the dirt. 

Several of the combine operators working in the 

nearby field tried several times to contact him by 2-way 

radio but could not reach him. Another employee, a truck 

driver, was asked to go to the decedent’s work location and check on him. The driver found the 

decedent under the combine and called the owner, but couldn’t reach him. The driver called 

another family member. Emergency response was called. While awaiting EMS arrival, one of the 

family members raised the combine head from the decedent and backed the combine 

approximately 15 feet away from him. 

CAUSE OF DEATH

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

negative for illegal, prescription and non-prescription drugs. 

Figure 3. Arrow pointing to sensing 

rod he may have been trying to unjam.

Figure 2. Sensing adjustment to the 

combine head.
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RECOMMENDATIONS/DISCUSSION

 Workers should always use all safety devices, such as hydraulic cylinder safety stops,

that machines are equipped with to prevent injury and exposure to hazards. If cylinder

safety stop is not available, block the raised combine head with a material, which will 

not crush under the weight of the unit.

Modern machines, including farm equipment are designed and equipped with a variety of 

effective safety devices, such as hydraulic cylinder safety stops. These devices protect workers 

while the machines are being used and during maintenance and repair of the machines. In this 

incident, the hydraulic cylinders that controlled the height of the combine header were equipped 

with a hydraulic cylinder safety stops. When moved and locked in its lowered position the safety 

stop would prevent the header from lowering due to a release of the bar, which controlled the 

adjustable floating head. Before crawling under the raised header the decedent did not lower and 

lock the safety stop or provide other secondary support, such as placing material under the raised 

head which will not crush under the weight of the unit should it come down. In this case, if the 

safety stop had been locked in place or secondary support provided this fatality would have been 

prevented.

 Calibrate header for each harvest site, evaluate ground site conditions and adjust 

harvesting procedures accordingly. 

The firm harvested 8000 acres in five counties. The number of acres and the diversity of crops 

and field conditions can make it challenging for machine operators to safely operate in fields due 

to changing conditions, unfamiliarity of terrain, etc. MIFACE recommends that the company 

develop a topographical diagram of each field. The company should survey each field during 

planting (when they perform planting or ask whoever plants the crop to do so) and note potential 

hazards on the corresponding diagram. During spraying activities or during other crop 

maintenance activities, the changes to terrain or other hazards (e.g. sagging overhead power 

lines, washouts, etc.) should be noted on the diagram. 

Weather events may also change field terrain during the course of the growing season. When 

harvesting the crop on that particular piece of farmland operators should check the site and 

consult the diagram to adjust harvesting activities accordingly. Perhaps if the operator was aware 

of the potential for a washout to occur, his harvesting approach may have been altered and the 

header would not have been jammed to the raised position.

 Use appropriate equipment shut off procedures when dismounting the equipment.

The operator’s manual should be consulted to determine the safe operating practices and 

procedures for the combine and any attached implements. Machine operators should shut down 

both the machine and the engine before inspecting or working on harvesting equipment. 

Operators should always disengage all power, shut off the engine and take the key. If the 
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combine had been turned off and the header’s automatic control shut down, when the decedent 

freed the head from its “stuck” raised position, it most likely would not have fallen onto him, 

assuming there was not a problem with the hydraulic system. 

 Combine manufacturers should install a safety interlock system, such as a seat safety 

switch for operator seats and offer retrofit seat safety switches.

Farm equipment, such as tractors and skid steer loaders, have a safety interlock system; tractors 

have a seat safety switch and many skid steer loaders have a seat bar, which prevent the 

machinery from being started and operated unless the operator is in the operator’s seat and 

progressing through an approved machine start procedure and automatically shuts down the 

equipment if it is left running when the operator leaves the seat. MIFACE recommends that 

combine manufacturers install a safety interlock system and develop and offer a retrofit seat 

safety switch for existing machines to interlock the machine’s operational functions to minimize 

the potential for operator injury and exposure to machine hazards.

KEY WORDS: Combine, Combine Header, Soybeans, Cylinder Lock, Machine, Struck By, 

Agriculture

REFERENCES

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 by writing to: Michigan 

Department of Licensing and Regulatory Affairs (LARA), MIOSHA Regulatory Services 

Section, Stevens T. Mason Building, 530 W. Allegan Street, Lansing, Michigan 48933, calling 

(517) 284-7740, or by FAX (517) 284-7735.

 MIOSHA General Industry Safety Standard, Part 53, Farm Field Equipment REF 

408.45301. http://www.michigan.gov/documents/CIS_WSH_part51-53_83015_7.pdf

 MIOSHA General Industry Safety Standard, Part 11, Recording And Reporting of 

Occupational Injuries and Illnesses

http://www.michigan.gov/documents/CIS_WSH_part11ad_37844_7.pdf

RESOURCES

 Harvesting Soybeans. Harvesting, Drying and Storing, Chapter 14. G. Huitnik. 

http://www.uaex.edu/publications/pdf/mp197/chapter14.pdf

 Farmer crushed by corn head when disengaging it from combine. Iowa FACE 

Program. Case Number 2008 IA 081 

http://www.cdc.gov/niosh/face/pdfs/08ia081.pdf
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 Farmer Dies After Being Pinned Beneath The Header Of A Combine in Minnesota.

Minnesota FACE Program. Minnesota FACE 00MN014

http://www.cdc.gov/niosh/face/stateface/mn/00mn014.html

 Laborer Killed After Being Run Over by the Tractor and Mower He was Operating.

Michigan FACE Program. MI FACE Investigation Report #07MI072. 

http://www.oem.msu.edu/MiFace/07MI072.pdf

 Farmer Dies After Being Crushed Beneath The Header Of A Combine. Minnesota 

FACE Program. MN FACE Investigation 01MN054. 

http://www.cdc.gov/niosh/face/stateface/mn/01mn054.html

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

(MSU) Occupational & Environmental Medicine, 909 Fee Road, 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 employer.

April 25, 2018