DATE: 

September 29, 2022

TIME:

7:50 a.m.

VICTIM:

46-year-old equipment 

operator

INDUSTRY/NAICS CODE:

Water and Sewer Line and 

Related Structures 

Construction/237110

EMPLOYER: 

Geothermal system 

installation

SAFETY & TRAINING:

Some elements existed

SCENE: 

Geothermal field 

installation

LOCATION:

Kentucky

EVENT TYPE:

Struck by

INCIDENT HIGHLIGHTS 

REPORT#: 22KY083 REPORT DATE: March 28, 2023

Equipment operator crushed by skid-steer 

attachment—Kentucky

SUMMARY

On September 29, 2022, a 46-year-old skid-steer operator was killed when 

he was struck by his skid-steer’s twin-fork attachment with a gravel bucket 

secured to it. The operator had raised the skid-steer’s arms and exited the 

cab. While the operator was beneath the attachment, it separated from 

the skid-steer’s lift arms and fell onto him. 

... READ THE FULL REPORT> (p.3)

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• Bypassing equipment safety features

• Workplace substance use

• Inadequate knowledge of hazards

• Inadequate training and communication

...LEARN MORE> (p.9)

RECOMMENDATIONS

Kentucky investigators concluded that, to help prevent similar 

occurrences, employers should:

• Ensure that employees do not bypass equipment safety features;

• Implement measures that contribute to a drug-free work

environment;

• Identify and understand the hazards that may be presented by

the equipment their employees operate;

• Provide education and training to employees to recognize

hazards and methods to mitigate and/or eliminate them.

...LEARN MORE> (p.9)

Kentucky FACE Program
Page 2

Fatality Assessment and Control Evaluation (FACE) Program

This case report was developed to draw the attention of employers and employees to a serious safety hazard and is based on 

preliminary data only. This publication does not represent final determinations regarding the nature of the incident, cause of the injury, 

or fault of employer, employee, or any party involved. 

This case report was developed by the Kentucky Fatality Assessment and Control Evaluation (FACE) program. Kentucky FACE is a NIOSHfunded occupational fatality surveillance program with the goal of preventing fatal work injuries by studying the worker, the work 

environment, and the role of management, engineering, and behavioral changes in preventing future injuries. The FACE program is

located in the Kentucky Injury Prevention and Research Center (KIPRC). KIPRC is a bona fide agent for the Kentucky Department for 

Public Health. 

Email | Twitter | Facebook| Website
REPORT#:22KY083 Page 3

INTRODUCTION

At 7:50 a.m. on September 29, 2022, a 46-year-old equipment operator was killed when he was struck by his skid-steer’s 

twin-fork attachment with a gravel bucket secured to it. The operator was using the skid-steer to fill the pipes of a 

geothermal water system with gravel. The operator had raised the skid-steer’s arms and then exited the cab with the 

machine still running. While the operator was beneath the attachment, it separated from the skid-steer’s lift arms and 

fell onto him. He was crushed against the cab and died of his injuries. 

EMPLOYER

The employer was a geothermal systems installation contractor that had been in business for approximately 18 years. The 

employer had a total of 19 employees, with three working at the scene at the time of the incident. 

WRITTEN SAFETY PROGRAMS AND TRAINING

Upper management declined participation in this investigation, so information regarding written safety programs and 

training was limited to details provided by foremen and employees. Interviewees indicated that skid-steer operators 

were informed that the operator’s manual for the skid-steer was located behind the operator’s chair in the cabs of all 

skid-steers on site. Interviewees also indicated that newly hired employees were assessed for competency of skid-steer 

operation by a process in which they were briefly observed operating the equipment by a foreman before being 

authorized to operate it independently. No written or formal training or safety program was reported.

WORKER INFORMATION

The 46-year-old skid-steer operator who was killed was not wearing any type of personal protective equipment (PPE) at 

the time of the incident. Likewise, worksite observations indicated that other employees were not using PPE and use 

was not required at the site. Several employees did wear brightly colored shirts and jackets (i.e., yellow and orange), but 

these items would not meet the specifications for high visibility apparel required by recent editions of ANSI/ISEA 107

American National Standard for High Visibility Safety Apparel and Accessories [ANSI/ISEA 107, 2023]. 

The skid-steer operator had worked for the geothermal systems installation contractor for a short time several years 

prior, then left to work for a different company and returned to the geothermal contractor approximately two years 

before the incident. It is unknown if the skid-steer operator received training upon his return to the company.

EQUIPMENT

A geothermal system was being installed in a field adjacent to a larger construction project. The process involved drilling 

holes into the ground vertically, installing a pipe into each hole, and installing a water line into each open pipe. Pipes 

were then filled with gravel from a gravel bucket carried by a skid-steer. The work area, with several pipes filled with 

gravel, are shown in Photo 1. 
REPORT#: 22KY083 Page 4

Photo 1. Geothermal system pipes (Property of KY FACE) 

The gravel bucket involved in the incident was secured to a twin-fork attachment of the skid-steer through fork slots and 

chain was used to provide additional stability. Gravel buckets similar to those involved in the incident are shown in 

Photo 2, and a gravel bucket secured to a twin-forks attachment in a configuration similar to the one involved in the 

incident is shown in Photo 3. The combined weight of the attachment, bucket, and gravel involved in this incident are 

estimated to be 2,000 pounds [EPA, 2016]. 

Photo 2. Gravel buckets (Property of KY FACE) Photo 3. Twin-forks attachment with gravel bucket 

(Property of KY FACE) 
REPORT#:22KY083 Page 5

INCIDENT SCENE

The scene was an outdoor area on level grade, estimated at 150 yards long by 75 yards wide. At the time of the incident

a geothermal system was being installed. Processes underway included the drilling of vertical holes, insertion of vertical 

piping into the drill holes, installation of water lines into the vertical pipes, and filling of the pipes with gravel. The scene 

on November 1, 2020, is shown in Photo 4. 

Photo 4. Incident Scene (Property of KY FACE) 

WEATHER

The weather at the time of the incident was approximately 45 degrees Fahrenheit, with a 3 mph north northeasterly

wind speed and 3 mph wind gusts [Weather Underground 2022]. There was a substantial amount of mud and standing 

water present, and the stability of the ground under the skid steer is unknown. These conditions are not considered to 

have played a significant part in the incident.

INVESTIGATION

Work was conducted over two 12-hour shifts (i.e., day/night). The incident occurred toward the end of the night shift, at 

7:50 a.m. Visibility is not considered to have been a factor in the incident, as interviews indicated that there were

adequate levels of light by virtue of temporary area lighting units and natural daylight. The coroner’s report included a 

drug screen that indicated the presence of amphetamines, methamphetamine, alprazolam, and fentanyl. 

Three employees were on site at the time of the incident. The decedent was operating a skid-steer, using it to fill vertical 

pipes of the geothermal system with gravel. The pipe-filling process required the coupling of the twin-forks attachment 

to the skid-steer lift arms, followed by the navigation of the skid-steer to insert the twin-forks into the fork slots of the 

gravel bucket. Chains were then used to secure the bucket to the twin-forks attachment. Next, the bucket was filled with 

gravel for filling vertical pipes. The pipe filling was accomplished by navigating the skid-steer into a position where the 

lift arms and bucket could be lowered close enough to the pipe opening to allow the gravel to be poured into the pipe 

opening. The skid-steer operator could perform most of these work processes from inside the cab. The coupling of the 

twin-forks attachment, for example, was performed from inside the cab using an operator’s switch that allowed 

automatic coupling. However, the operator would have to lower the lift arms and exit the cab to secure the chains. The 

operator would then have to re-enter the cab to drive the skid-steer with bucket attachment to an area where the 

bucket would be filled with gravel. 
REPORT#: 22KY083 Page 6

Filling was likely accomplished using a backhoe bucket to scoop gravel from a pile and drop it into the top of the gravel 

bucket. That process would have required the operator to again lower the lift-arm and bucket and exit the skid-steer cab

to operate the backhoe. Once the bucket was filled with gravel, the skid-steer operator would have to re-enter the cab,

raise the lift-arm, and navigate the skid-steer to the vertical pipes. The pipe filling would proceed until all pipes were 

filled or the gravel bucket was empty and had to be refilled. 

Two other employees were operating drilling equipment located on the far side of the work area from the skid-steer 

operator’s activities. The drill operators did not witness the incident, but at some point one of them noticed that the 

skid-steer operator had exited the skid-steer and had become pinned against the cab. The twin-forks attachment had 

detached from the lift arms of the skid-steer, and the twin-forks attachment and gravel bucket had fallen onto the skidsteer operator. The skid-steer, detached twin-forks attachment, and bucket are shown in Photo 5. 

Photo 5. Skid-steer with twin-fork attachment and bucket (Courtesy of coroner). 

The operator was struck by the twin-forks attachment and bucket because he was located in the crushing zone when the 

twin-forks attachment separated from the lift arms. The crushing zone is illustrated in red in Diagram A. 
REPORT#: 22KY083 Page 7

Diagram A. Crushing Zone (KYSAFE [n.d.]. Hazard Alert: Skid-Steer Loader video). 

When the drill operators became aware of the incident, they walked over to help the skid-steer operator but could not 

remove the twin-forks attachment and bucket by hand. At the same time, a foreman from the day shift had arrived at 

the site and the drill operators walked over to tell him of the incident. The foreman directed one of the drill operators to 

call 9-1-1 for help. The three employees then worked to free the skid-steer operator, using a second skid-steer to lift the 

twin-forks attachment and gravel bucket off of him. 

The skid-steer was designed to accept a variety of attachments. The twin-forks attachment involved in the incident 

secured to the skid-steer using a quick hitch built into the skid-steer’s lift arms that inserted into slots on the twin-forks 

attachment. Once the quick hitch was inserted, two locking pins on the quick hitch were engaged to fully secure the 

attachment to the lift arms. A scoop attachment, which is attached to the lift arms in a similar fashion as the twin-fork 

attachment involved in the incident, is shown in Photo 6. The locking pins are detailed in Photos 7 and 8. 

Photo 6. Skid-steer with scoop attachment (Courtesy of KY FACE). 
REPORT#: 22KY083 Page 8

Photo 7. Skid-steer locking pin (Courtesy of KY FACE). 

Photo 8. Detail of locking pin (Courtesy of KY FACE). 

Employee interviews indicated that an equipment malfunction had likely occurred such that one or both of the two 

locking pins that secured the forks onto the arms of the skid-steer were not properly in place. Interviewees speculated 

that the presence of mud, rock, and other debris may have prevented the pin(s) from being securely locked into place. A 

visual inspection of the equipment, after coupling the attachment to the lift-arm, is necessary to ensure that the pins are 

properly secured in place. 

It is not known why the skid-steer operator exited the cab with the lift arms in the raised position. The skid-steer 

operator did not engage the skid-steer’s lift arm stopper brace, indicated in Photo 9. The lift arm stopper is a safety 

device provided as original equipment by the skid-steer manufacturer. The stopper serves to safely brace the lift arm, 

should it be necessary to leave it in a raised position. The stopper brace did not play a direct role in the incident. 

When the skid-steer operator was found pinned against the cab, the safety bar was in the lowered position and the 

engine was running. The safety bar is a feature found on the type of skid-steer involved in the incident that serves to 

disengage power to the machine’s engine and controls whenever the safety bar is raised. When an operator enters the 

cab and sits in the operator’s chair, they must first lower the safety bar to start the engine and proceed with operation. 

Conditions noted by the coroner indicate that after exiting the cab, the skid-steer operator lowered the safety bar and 

started the skid-steer’s engine, bypassing the safety feature. It is not known why the safety bar was lowered.
REPORT#: 22KY083 Page 9

Photo 9: Lift arm stopper brace (Courtesy of coroner)

CAUSE OF DEATH 

According to the coroner’s report, the cause of death was multiple blunt force/crush injuries.

CONTRIBUTING FACTORS 

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger 

sequence of events that ultimately result in the injury or fatality. Kentucky FACE has identified the following 

unrecognized hazards as key contributing factors in this incident:

• Bypassing equipment safety features

• Workplace substance use

• Inadequate knowledge of hazards 

• Inadequate training and communication 

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should ensure that employees do not bypass equipment safety features.

Discussion: Employers should ensure that their employees utilize equipment safety features rather than bypass them. 

The seat bar, also referred to as safety bar, is an essential safety device for skid-steers that should be used in accordance 

with the manufacturer’s instructions. The operator’s manual for the skid-steer directed that the operator should raise 

the safety bar before standing up from the operator’s seat and lower the lift arms to the ground before exiting the cab. 

If the lift arms were needed to be left in the raised position, then the lift arm stopper was to be engaged.
REPORT#: 22KY083 Page 10

OSHA [2009] has issued guidance that specifically focuses on the hazards presented by bypassing skid-steer safety 

devices, providing several case studies in which the safety bar was bypassed and serious or fatal injuries resulted. In this 

incident, the protective quality of the safety bar was negated because the device was not utilized. Regarding the lift 

arms, the National Institute for Occupational Safety and Health (NIOSH) [2011] recommends: “Use the lift-arm support 

device provided by or recommended by the manufacturer any time it is necessary to work or move around the machine 

with the lift arm in a raised position.”

Recommendation #2: Employers should ensure that employees follow equipment manufacturer’s instructions.

Discussion: Employers should ensure that employees follow the instructions provided by the equipment manufacturer

for the specific type of equipment that they operate. The operator’s manual for the skid-steer involved in this incident 

provided explicit directions and safe operating procedures, such as provisions that any operation of any lever, pedal, or 

switch should only be performed when the operator is sitting in the seat. It was the employer’s practice to keep the 

operator’s manual in a designated storage slot behind the seat in the cab. Also, generic guidance on safe skid-steer

operation is available to reinforce and supplement manufacturer’s guidance. For example, guidance published by the 

Association of Equipment Manufacturers (AEM) requires that the operator should “never leave the operator’s seat 

without lowering the bucket or other attachment flat on the ground” [AEM, 2009]. 

Recommendation #3: Employers should implement measures that contribute to a drug-free work environment, 

including the development and implementation of an alcohol- and drug-free workplace program, particularly for jobs 

related to machine operation.

Discussion: A post-mortem blood test from the skid-steer operator reported the presence of amphetamines, 

benzodiazepines, and opioid analgesics. Interviewees did not indicate that they had noticed that the skid-steer operator 

exhibited any signs of intoxication. Employers should consider designing and implementing an appropriate alcohol- and 

drug-free workplace program that matches the needs of their organization. Such programs are often unique to the 

individual company and include measures that are feasible, applicable, and beneficial to that workforce.

Employers may find it useful to research how similar businesses and industries in their local area have addressed this 

issue. Drug testing is only one component of a comprehensive drug-free workplace program and may or may not be 

appropriate according to applicable federal and state laws and regulations. Other components that are important to 

consider in a comprehensive program include a clear drug-free workplace policy that specifies prohibited behaviors and 

consequences, supervisor training, an Employee Assistance Program, and employee education. 

Recommendation #4: Employers should effectively identify and understand the hazards that may be presented by the 

equipment their employees operate and are exposed to. 

Research by NIOSH [2011] suggests that that many employers and workers likely do not understand the hazards 

associated with operating skid-steers. In order to adequately address, identify, and understand workplace hazards, 

OSHA [2016] recommends that employers first collect information about job site hazards from sources such as

equipment operating manuals, input from employees, and job hazard analyses; second, employers should “conduct 

frequent and regular inspections of the job site to identify new or recurring hazards.” It is best if such hazard 

identification and assessment measures are incorporated with the other key elements of a safety and health program 

e.g., management leadership, employee participation, hazard prevention and control, education and training, and

program evaluation and improvement).
REPORT#: 22KY083 Page 11

Recommendation #5: Employers should provide education and training to employees to recognize actual or potential 

hazards and methods to mitigate or eliminate hazards.

Discussion: Specific details regarding worksite hazards and control measures should be effectively communicated to 

employees through education and training. OSHA [2009] recommends that employers “train personnel on the proper 

inspection, use, maintenance, and repair of skid-steer loaders according to the manufacturer’s instructions. Train 

supervisory personnel to identify hazards, such as safety systems that have been bypassed, disabled, or that require 

maintenance.” Education and training programs should include a means by which a minimum level of proficiency of 

trained employees can be assured. OSHA [2015] guidance notes that workplace safety training should include an 

evaluation to ensure that workers received the level of knowledge and skill needed. Assessment of student learning “can 

be accomplished through activities such as demonstration skills or testing.” When equipment safety features are 

utilized, employers should provide clear and explicit information regarding how such equipment provides protection to 

employees from hazards including the possible consequences of bypassing safety features. 

DISCLAIMER

Mention of any company or product does not constitute endorsement by Kentucky FACE and NIOSH. In addition, 

citations to websites external to Kentucky FACE and NIOSH do not constitute NIOSH endorsement of the sponsoring 

organizations or their programs or products. Furthermore, Kentucky FACE and NIOSH are not responsible for the content 

of these websites. All web addresses referenced in this document were accessible as of the publication date.

REFERENCES

American National Standards Institute. [2023]. ANSI/ISEA 107 American National Standard for High Visibility Safety 

Apparel and Accessories. 

Environmental Protection Agency, Office of Resource Conservation and Recovery. [2016]. Volume-to-Weight Conversion 

Factors. 

KYSAFE [n.d.]. Hazard Alert: Skid-Steer Loader video. Kentucky Education and Labor Cabinet. 

National Institute for Occupational Safety and Health. [2011]. NIOSH Alert: Preventing Injuries and Deaths from SkidSteer Loaders. Centers for Disease Control and Prevention.

Oklahoma FACE Program. [2004]. Oklahoma Case Report: 04-OK-058-01: An Elevator Operator Was Killed When He Fell 

from a Manlift.. 

Oregon FACE. [2019]. REPORT#: 2018-08-1: Fatality Investigation Report: Skid-Steer Operator Crushed While Controlling 

the Skid-Steer from Outside the Cab. 

Occupational Safety and Health Administration. [2009]. Hazards Associated with Operating Skid-Steer Loaders with 

Bypassed and/or Improperly Maintained Safety Devices.

Occupational Safety and Health Administration. (2015). OSHA 3824: Resource for Development and Delivery of Training 

to Workers.

Occupational Safety and Health Administration. (2016). OSHA 3886: Recommended Practices for Safety and Health 

Programs in Construction.

Weather Underground [2022]. Weather History for KKYELIZA135. The Weather Channel Interactive, Inc.

ADDITIONAL RESOURCES

Association of Equipment Manufacturers [n.d.]. Skid-Steer Safety Manual for Operating and Maintenance Personnel, 

FORM SL02-12. 

Gorucu, S., Weichelt, B. & Burke, R. [2022]. Injuries and Fatalities Related to Skid-Steers: 2015–2020. Safety, 8(56), 56. 
REPORT#: 22KY083 Page 12

KYSAFE [n.d.]. Hazard Alert: Skid-Steer Loader. Kentucky Education and Labor Cabinet.

Substance Abuse and Mental Health Services Administration. [2022]. Model Plan for a Comprehensive Federal Drug-Free 

Workplace Program. HHS Publication No. (ADM)90-1635. Department of Health and Human Services.

INVESTIGATOR INFORMATION

This investigation conducted and report prepared by Dr. David Stumbo, OHST, CSP. 

ACKNOWLEDGMENT

The Kentucky FACE Program would like to acknowledge the assistance provided by the Kentucky Education and Labor 

Cabinet toward this report.