FATALITY INVESTIGATION REPORT

DATE: 

March 30, 2018

TIME:

2:30 p.m.

VICTIM:

36-year-old male skid-steer 

operator

INDUSTRY/NAICS CODE:

Construction/23

EMPLOYER: 

Foundation support, 

excavation and site 

preparation

SAFETY & TRAINING:

Safety meetings & training 

facilitated by employer

SCENE: 

Construction, site preparation

LOCATION:

Oregon

EVENT TYPE:

Caught-in or -between

INCIDENT HIGHLIGHTS

 

Skid-steer operator crushed while controlling the skidsteer from outside the cab. 

REPORT#: 2018-08-1 REPORT DATE: September 2019

________________________________________________________ 

SUMMARY 

On March 30, 2018, a 36-year-old male skid-steer (track loader) operator 

was caught between the cab and lift arm. Nearby security video captured 

the event. Installation of helical piers, foundation support anchors, had 

been completed. The operator was attempting to disconnect the employer 

fabricated helical hydraulic head attachment from the last installed helical 

pier. He was controlling the skid-steer while standing in front of the cab in 

between the lift arms front frame rail cross member. A hydraulic hose that 

had been wrapped around the right control lever of the skid-steer pulled 

the control lever forward and when the operator pulled the safety bar 

down, the right lever was engaged causing the lift arms to lower, crushing 

the operator. The operator was pronounced dead at the scene. (Full 

report begins on p. 3)

________________________________________________________ 

CONTRIBUTING FACTORS 

Key contributing factors identified in this investigation include: 

 Operating a skid steer outside the cab and bypassing a safety feature

 Not following manufacturer’s instructions

 Inadequate knowledge of hazards 

 Inadequate training and communication 

(Contributing factors continued on p. 5) 

______________________________________________________ 

RECOMMENDATIONS 

Oregon Fatality Assessment and Control Evaluation (OR-FACE) 

investigators concluded that to help prevent similar occurrences, 

employers should: 

 Employers should ensure that employees operate a skid-steer inside of 

the cab and should not bypass its safety features. 

 Employers/employees should review and adhere to equipment 

manufacturer operating manual.

 Employers should train employees to identify hazards such as caughtin/between hazards and methods to mitigate or eliminate hazards.
Page 2

OR-FACE supports the prioritization of safety interventions using a hierarchy of safety controls, 

where top priorities are hazard elimination or substitution, followed by engineering controls, 

administrative controls (including training and work practices), and personal protective equipment. 

Oregon Fatality Assessment and Control Evaluation (FACE) Program

The Oregon Fatality Assessment and Control Evaluation (OR-FACE) Program is a project of the Oregon 

Institute of Occupational Health Sciences at Oregon Health & Science University (OHSU). OR-FACE is 

supported by a cooperative agreement with the National Institute for Occupational Safety and Health 

(NIOSH) (grant #U60OH008472) through the Occupational Public Health Program (OPHP) of the Public 

Health Division of the Oregon Health Authority. OR–FACE reports are for information, research, or 

occupational injury control only. Safety and health practices may have changed since the investigation 

was conducted and the report was completed. Persons needing regulatory compliance information 

should consult the appropriate regulatory agency.
REPORT#: 2018-08-1 Page 3

INTRODUCTION 

On Friday, March 30, 2018, a 36-year-old construction worker was operating a skid-steer (track loader) with an 

employer-fabricated helical pier hydraulic head attachment. The worker and his foreman were on site installing helical 

piers (also known as anchors, piles or screw piles) to provide support for a new building’s foundation. A review of 

footage recorded by a security camera from a nearby business showed that the worker was operating the skid-steer 

standing outside of the cab. He was attempting to release the pressure from the pin connecting the skid-steers helical 

pier head attachment to the helical pier that was previously installed. 

BACKGROUND 

According to OSHA, “Control Interlock Systems and/or operator seats used on some machines typically activate a safety 

interlock system that is intended to prevent inadvertent movement of the machine's controls when the operator is not 

in the proper operating position (i.e., seated). Review of OSHA's 

Integrated Management Information System (IMIS) reveals that between 

1997 and 2007, 100 accidents were recorded specifically involving skidsteer loaders. The deliberate bypassing of safety features (such as 

seatbelts and control interlock systems) was identified as the direct 

cause of 20% of these incidents, with all but one resulting in a fatality” 

(see reference #1-US Department of Labor, OSHA). 

Helical piles and piers are used to repair building foundation or as a 

ground anchoring system used when deep foundations are required. 

They are made of steel and contain helices just like screws. They are 

driven into the soil by use of a hydraulic system to bedrock or other 

stable strata. They are designed to limit stress on the surrounding soil, 

reducing environmental impact. They typically do not require cure time 

or excavation. 

The skid steer and other heavy equipment are made versatile with different attachments. Several manufacturers 

market attachments specific for skid-steers and can vary from augers, bale handlers to concrete breakers. Helical pier 

hydraulic head attachments to drive helical piers into the soil are available from several manufacturers. 

EMPLOYERS 

The skid-steer operator worked for a small company of 5 employees. The company specialized in deep foundation 

support, excavation and site preparation and had been in business for approximately five years. 

WRITTEN SAFETY PROGRAMS and TRAINING 

A written accident prevention program that included a disciplinary policy was provided to all employees. According to 

the company trainer, equipment operator training included a review of: (1) all safety functions, (2) operation functions, 

(3) equipment manual to ensure understanding of limitations/capacities and how to conduct daily inspection and testing 

to ensure good working conditions prior to start of the job.

Photo 1: Seat bar (control interlock) of a skidsteer shown in raised position. (Photo from 

Department of Labor, OSHA, see Reference 

#1).
REPORT#: OR 2018-08-1 Page 4

WORKER INFORMATION 

The operator worked for the employer approximately one year. He had been operating a skid-steer for seven months. 

INCIDENT SCENE 

The incident occurred at a site where a new building was being constructed. Helical piers were installed to support the 

foundation of the new building and transfer the weight below the neighboring building basement. 

WEATHER 

Weather did not appear to be a factor. According to Weather Underground – Historical Weather, the high temperature 

on the day of the incident was 58 degrees Fahrenheit (F) and zero precipitation. The temperature at the time of the 

incident was approximately 57 degrees F. Wind speed was CALM, 0 mph.

INVESTIGATION 

The two-day project of installing helical piers (also known as anchors, piles or screw piles) for support of a new building’s 

foundation and transfer the weight below the neighboring building basement began on March 29, 2018. On the second 

day, Friday, March 30 the foreman and 

equipment operator arrived at the worksite 

around 8:00 am to finish the installation of 

remaining helical piers. Twelve were installed 

approximately five feet apart to a depth of 

approximately 32 feet. At 2:30 pm the 

foreman instructed the operator to stop work 

and take a break. Only one more helical pier 

remained to be installed. The foreman left 

the site to use the facilities at a restaurant 

next door. 

Video surveillance camera at a nearby 

business recorded the event. The operator 

stepped outside of the cab, left it running 

while attempting to release the pressure from 

the pin connecting the skid-steer’s helical 

head attachment (which drives the helical pier 

to appropriate depth) to the installed helical 

pier. He positioned himself in front of the cab 

and in between the lift arms front frame rail 

cross member. 

Photo 2: Skid-steer at the site; (Photo courtesy of OR-OSHA)

Skid-steer lift arm

Helical pier hydraulic head attachment

attachmentattachmentattachment
REPORT#: OR 2018-08-1 Page 5

A hydraulic hose connected to the head attachment 

had been wrapped around the right control lever and 

pulled the control lever towards the front of the 

skid-steer (see Photo 3). When the operator pulled 

the safety bar (also known as seat bar-see photo 1) 

down it engaged the functions of the equipment and 

the right control lever caused the lift arms to lower, 

crushing the operator. 

When the foreman returned to the site he saw a 

bystander yelling and pointing to the skid-steer. As 

he approached the skid-steer he saw the operator 

caught between the cab and the lift arms cross 

member. The foreman then entered the skid-steer, 

raised the lift arms and pulled the operator out and 

onto the ground next to the skid-steer. 

Several bystanders and a physician assistant 

provided medical attention at the scene until First Responders arrived. The operator was pronounced deceased at the 

scene. 

As reported by the trainer, operator training included a review of: (1) all safety functions, (2) operation functions, (3) 

equipment manual to ensure understanding of limitations/capacities and how to conduct daily inspection and testing to 

ensure good working conditions prior to start of the job. The trainer was present on the first day of the project and 

observed the operator. He did not notice any actions that were concerning. 

Documents and interviews revealed that the helical pier hydraulic head attachment was fabricated by the employer. 

The Oregon OSHA investigator noted that a thread bolt used to stabilize the attachment was worn and bent, and 

hydraulic hose sleeves were worn. Documents were not provided on the limits and specifications of the helical pier 

hydraulic head attachment. During the review of the manufacturer’s skid-steer equipment manual, pages, 1-10, the 

following statements were found, “Consult with manufacturer before installing an optional attachment,” and “Do not 

use attachments that have not been approved by manufacturer. Doing so may compromise safety or adversely affect the 

machine’s operation or service life.” According to interview documents, the skid-steer manufacturer was not consulted 

in the design or approval of the attachment. Neither was it certified by an engineer. 

Company policy and working procedures for installing helical piers required a minimum of two employees on site at all 

times. This was to ensure that the depth of installation and the correct pressures were logged throughout the 

installation process. It was stated during the interview that “one operator cannot do all the work without exposing 

himself to hazards.” 

CAUSE OF DEATH 

According to Oregon Vital Records data, the cause of death was asphyxia.

Photo 3: Hydraulic hose wrapped around control lever; (Photo 

courtesy of OR-OSHA
REPORT#: OR 2018-08-1 Page 6

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. OR-FACE investigators identified the following factors 

that may have contributed to this incident: 

 Operating a skid-steer from outside the cab and bypassing the safety feature

 Not following manufacturer’s instructions

 Inadequate knowledge of hazards 

 Inadequate training and communication 

RECOMMENDATIONS/DISCUSSION 

 Recommendation #1: Employers should ensure that employees operate a skid-steer inside of the cab and should 

not bypass its safety features. 

Discussion: “Review of OSHA's Integrated Management Information System (IMIS) reveals that between 1997 and 

2007, 100 accidents were recorded specifically involving skid-steer loaders. The deliberate bypassing of safety 

features (such as seatbelts and control interlock systems) was identified as the direct cause of 20% of these 

incidents, with all but one resulting in a fatality” (see Reference #1).

NIOSH report (see Reference #2) stated that fatal skid-steer incidents suggest that employers and workers may not 

fully appreciate the potential hazards associated with operating or working near skid-steer loaders, the need to 

follow safe work procedures, and the consequences of bypassing interlocks and other safety features. Regarding the 

hazard associated with the lift arms, NIOSH recommends: “Lift-arm support—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. Machines now being manufactured have either pin-type support devices (which 

can be operated from inside the operator’s cab) or strut-type support devices (which may also be operated from 

inside the cab or may require the help of a coworker).”

The operator exited the cab and positioned himself below the raised lift arm without the use of a support device. 

NIOSH further recommends that, -“If the machine is not equipped with a lift-arm support device or it is damaged, 

contact the equipment dealer or manufacturer’s representative for help in determining proper support procedures 

or for replacement parts. Never use concrete blocks or simple metal angle irons because they can shift or collapse 

under even light loads.”

 Recommendation #2: Employers and employees should review and adhere to equipment manufacturer operating 

manual.

Discussion: The helical pier hydraulic head attachment was fabricated by the employer who failed to follow the 

manufacturer’s operating manual that stated, “Consult with manufacturer before installing an optional attachment,” 

and “Do not use attachments that have not been approved by manufacturer.” An OR-FACE Alert was published (see 

Reference #3) after fatalities occurred in Oregon because manufacturer instructions were disregarded. 

There was difficulty removing the helical pier hydraulic head attachment from the installed pier. It appears that this 

prompted the operator to exit the cab, place himself in a hazardous situation while attempting to separate the 

installed helical pier and the attachment. The condition of the attachment (worn and bent thread bolt) may have 

indicated problems with the design and may have contributed to the problem. 
REPORT#: OR 2018-08-1 Page 7

Research of skid-steer attachments revealed that there are several manufacturers of many different attachments. 

Some specify compatibility with a model of skid-steer and many do not. Prior to purchasing or fabricating an 

attachment, employers should consult the skid-steer manufacturer. If purchased, the employer should ensure that 

the attachment manufacturer obtained approval from the equipment manufacturer. 

 Recommendation #3: Employers should train employees to identify hazards such as caught-in/between hazards 

and methods to mitigate or eliminate hazards. 

Discussion: According to CPWR’s Fourth Quarter Report (see Reference #4) “Caught-in/between hazards are one of 

the major causes of fatal and nonfatal injuries in construction. During the period of 2011 to 2015, 275 construction 

workers died from caught-in/between injuries, more than in any other major industry. Construction also had an 

elevated risk of nonfatal caught or compressed by injuries among all industries. Hazards leading to fatal and nonfatal 

caught-in/between injuries in construction were quite different. More than two in three (68.6%) of caughtin/between fatalities occurred when workers were caught or crushed in collapsing materials, while about 93% of 

nonfatal caught-in/between injuries were a result of workers being caught or compressed by objects or equipment.”

It was the afternoon at the end of the workweek, and the job was almost complete (i.e., one helical pier left to 

install). Perhaps, in the operator’s haste to complete the job and start the weekend, he failed to take the time to 

think about the consequence of what he was about to do. The employer was aware that “one operator cannot do 

all the work without exposing himself to hazards.” It was not evident that employees were trained on these hazards 

or methods to mitigate them. 

Caught-in/between accidents in construction are part of OSHA’s Focus Four initiative. As a result, OSHA Directorate 

of Education and Training has published an Instructor Training Guide on caught-in/between hazards (see Reference 

#5). 

DISCLAIMER 

Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety 

and Health (NIOSH) or OR-FACE. In addition, citations to websites external to NIOSH or OR-FACE do not constitute 

endorsement of the sponsoring organizations or their programs or products. Furthermore, neither NIOSH nor OR-FACE is 

not responsible for the content of these websites. All web addresses referenced in this document were accessible as of 

the publication date. 

REFERENCES 

1. Hazards associated with operating skid-steer loaders with bypassed and/or improperly maintained safety devices-US 

Department of Labor, OSHA 

https://www.osha.gov/dts/shib/shib011209.html

2. Preventing injuries and deaths from skid-steer loaders-CDC, National Institute for Occupational Safety and Health 

https://www.cdc.gov/niosh/docs/2011-128/default.html

3. OR-FACE Alert: Follow manufacturer’s instructions-Oregon Fatality Assessment and Control Evaluation 

https://www.ohsu.edu/sites/default/files/2019-02/ORFACE-Pub-HazAlert-ManufacturersInstruction-Eng.pdf
REPORT#: OR 2018-08-1 Page 8

4. “Caught-in/between injuries and Prevention in Construction Industry.” CPWR Quarterly Data Report. CPWR Data 

Center. 

https://www.cpwr.com/sites/default/files/publications/Quarter4-QDR-2017.pdf

5. Construction Focus 4: Caught-in or -between hazards Instructor Guide. OSHA Directorate of Training and Education. 

2011.

https://www.osha.gov/dte/outreach/construction/focus_four/caught/caught_iorb_ig.pdf

6. Skid-steer Loader Safety-Kansas State University Research and Extension 

http://nasdonline.org/1924/d001877/skid-steer-loader-safety.html

INVESTIGATOR INFORMATION 

This investigation was conducted by Illa Gilbert-Jones, OR-FACE Program. The report was reviewed and received input 

from Ryan Olson, PhD, Director, OR-FACE Program, and the OR-FACE Publications Review Panel. 

ACKNOWLEDGEMENT 

The Oregon FACE Program would like to acknowledge the compliance officer and staff of Oregon Occupational Safety 

and Health (Oregon OSHA), a division of the Oregon Department of Consumer & Business Services for providing 

assistance and information during this investigation.