DATE: 

Winter 2015

TIME: 

Between 10am-11am

VICTIM:

Farm Land Landlord

INDUSTRY/NAICS CODE:

Real Estate & Rental & 

Leasing/53

EMPLOYER: 

Self-Employed

SAFETY & TRAINING:

Previous Dairy Farmer, 

familiar with tractor 

operation

SCENE: 

Farm Field Tree Line

LOCATION:

Michigan

EVENT TYPE: 

Machine/Struck By

___________________________

INCIDENT HIGHLIGHTS

REPORT#: 15MI064 REPORT DATE: 10/23/18

Owner of Farm Land Pinned Under Tractor 

While Clearing Fence Line

________________________________________________________ 

SUMMARY

In winter 2015 a male owner of farm land in his 60s died when a John 

Deere 2240 tractor fell onto him. He was using the tractor, which was 

equipped with a bucket, to move small trees and brush he had previously 

cut from the fence row. While backing up the tractor, it became stuck and 

elevated slightly, most likely from a tree. He got off the tractor and walked 

back to his house to pick up a screwdriver and a bushman’s saw (similar to

a hack saw). Returning to the tractor, he went under the tractor with the 

tractor in gear and PTO running, to saw the log/tree that had contributed 

to the tractor to becoming stuck. When the log/tree was sawn through, the 

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

________________________________________________________ 

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• The tractor was running, in gear, with PTO rotating when he

went under the tractor.

• Front tractor tires not chocked or blocked

• Elevated tractor not supported when decedent worked under

the tractor.

LEARN MORE> (p.4)

______________________________________________________ 

RECOMMENDATIONS

MIFACE investigators concluded that, to help prevent similar 

occurrences, employers should: 

• Utilize proper tractor shut-off procedures prior to exiting the

tractor seat.

• Always provide secondary support when working under an

elevated piece of equipment. LEARN MORE> (p.5)

https://oem.msu.edu
Page 2

Michigan Fatality Assessment and Control Evaluation (FACE) Program

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.
REPORT#: 15MI064 Page 3

SUMMARY

In Winter 2015 a male owner of farm land in his 60s died when a John Deere 2240 tractor fell onto him. He was using 

the tractor, which was equipped with a bucket, to move small trees and brush he had previously cut from the fence row 

into one of the fields he rented out. While backing up the tractor, it became stuck and elevated slightly, most likely from 

a tree. He got off the tractor and walked back to his house to pick up a screwdriver and bushman’s saw (similar to a hack 

saw). It is unknown if the tractor was left running when he went back to the house. Returning to the tractor, he went 

under the tractor with his body near the left rear tractor wheel. The tractor was in gear and PTO running. Using the 

bushman’s saw he sawed the log/tree that had contributed to the tractor to becoming stuck. After the tree was sawn 

through, the tractor fell to the ground. Based on both clothing damage and injuries, he may have come into contact with 

the rotating power take off (PTO). He was found by a family member under the left rear tractor wheel. Emergency 

response was called and he was declared dead at the scene. 

INTRODUCTION

MIFACE personnel contacted the family of the deceased who agreed to be interviewed by MIFACE personnel. MIFACE 

reviewed the death certificate and police report during the writing of this report. Pictures used in the were taken by the 

MIFACE researcher at the time of the site visit.

EMPLOYERS

The decedent had been involved in dairy farming since the 1950s. He worked off the farm as a truck driver for another 

dairy farm and came back to the family farm in 1978, and with other family members, ran it full time. He sold the family

dairy farm approximately 2 years ago and now leased out the 88 tillable acres of the total 120 acres to another farmer 

who grew soybeans. The decedent performed fence line maintenance as part of his agreement with the lease. 

WRITTEN SAFETY PROGRAMS and TRAINING

It was not known by the family if the decedent had the tractor’s operating manual.

WORKER INFORMATION

The decedent had been raised on a dairy farm. He was familiar with the 4-wheel drive John Deere 2240 tractor 

operation; he had been using the tractor for the past five years. According to his family, the decedent worked at a fast 

pace, was “impulsive” and “in a hurry to do things”. 

INCIDENT SCENE

The incident occurred in farm field fence line approximately one-quarter mile from the decedent’s home. The decedent 

was in the process of moving the cut/downed trees and brush into the adjacent farm field. There was approximately 5.0 

inches of snow on the ground. The family stated the ground was muddy under the snow. The decedent was working 

alone. He had borrowed the tractor bucket attachment from the farmer who rented his fields.

WEATHER

Weather Underground was utilized to check the weather conditions on the day of the incident. The temperature was 

240

F with scattered clouds and north winds between 11-12 mph, resulting in a wind chill index temperature of 120F130

F. [Weather Underground]
REPORT#: 15MI064 Page 4

INVESTIGATION

The decedent had been clearing fence rows for two days around his rented fields to expand the land available for rent. 

On the day of the incident, at daylight he went to incident field. He cut down several trees and cleared out some brush. 

He backed the tractor into the fence row and lifted/carried/pushed the downed trees and brush from the fence row into 

the field to permit easier cleanup. He was wearing a heavy coat, gloves and a “dew rag” on his head. 

While backing up-his tractor (See Figure 1), the tractor became stuck and elevated slightly, most likely from a tree. The 

front wheels of the tractor were on the ground, but the back wheels were not on the ground and it appears that the 

tractor could not gain traction to move in either direction. The decedent climbed off the tractor and walked back to his 

house approximately one quarter of a mile away to pick up a screwdriver and Bushman bow saw (similar to a hack saw). 

A family member took him back to the field with his tools; the family member waited in his vehicle, parked near the 

field. After returning to the tractor, the decedent went under 

the tractor with his body near the left rear tractor wheel. The 

tractor was in gear and PTO was running. Using the bushman’s 

saw he sawed the tree/brush that had contributed to the 

tractor to becoming stuck. After the tree was sawn through, 

the tractor fell to the ground. Because the tractor was running 

and still in gear, it moved forward pinning the decedent under 

the left rear tractor wheel. At some point, it appears his face 

and clothing contacted the rotating PTO. 

The family member sat in his vehicle for approximately 20-25 

minutes. As the decedent worked, the family member lost 

sight of him. The family member returned to his home to get 

his coat, boots and gloves so he could walk to the decedent’s 

location to check on him. After donning the clothing, he walked 

until he came to the decedent’s location. He did not see the 

decedent, and assumed the decedent had returned to his 

house for more tools or other work items. After walking around 

the tractor, he looked under the tractor and caught sight of the decedent’s jacket. Looking further, he saw the decedent 

under the left rear tractor wheel, on his back in the mud/snow. The tractor had stalled by the time the family member 

found the decedent. The family member turned the ignition key to the off position.

The family member went back to the farmhouse and called for emergency response. The tractor was lifted from the 

decedent. He was declared dead at the scene. Responders found his Bushman’s saw beneath him. 

CAUSE OF DEATH 

The death certificate listed the cause of death as asphyxiation due to or as a consequence of entrapment beneath a 

tractor tire. No autopsy was performed. 

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. The following unrecognized hazards were identified as 

key contributing factors in this incident:

Figure 1. Tractor involved in incident
REPORT#: 15MI064 Page 5

• The tractor was running, in gear, with PTO rotating when he went under the tractor. 

• Front tractor tires not chocked or blocked

• Elevated tractor not supported when decedent worked under the tractor.

• Working alone.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Tractor operators should always utilize proper tractor shut-off procedures prior to exiting the 

tractor seat.

Discussion: Tractor operators should follow safe shut down procedures prior to dismounting the tractor. The tractor 

operator manual should be followed for any specific instructions. If a manual is not present, it should be requested. 

For their own safety and that of bystanders, operators should never leave the driver’s seat of a tractor that is still 

running. Before dismounting the tractor, operators should always: 

• Disengage the PTO and lower all implements to the ground 

• Place all controls in the neutral position

• Place the transmission in park lock, or if a manual transmission, place in the lowest gear 

• Set the parking brake(s) 

• Stop (turn off) the engine 

• Remove the key

Recommendation #2: When working under an elevated piece of equipment, always provide a secondary means of

support. If wheels are in contact with the ground, block/chock these wheels to prevent equipment movement. 

Discussion: Rule 34 (Machine Guards and Devices) of the MIOSHA General Industry Safety Standard, Part 1, General 

Provisions offers farm owners sage advice. Rule 34, Subpart (12) states that “an employee shall not place his/her body 

beneath equipment, such as vehicles, machines or materials, supported only by a jack, overhead hoist, chain fall, or any 

other temporary single supporting means, unless safety stands, blocks or other support system capable of supporting 

the total imposed weight is used to protect the employee in case of failure of the supporting system.” The decedent did 

not provide any method of secondary support while working under the tractor. 

When working on a large piece of equipment that is elevated, consideration should be given to the center of gravity of 

that object. An elevated load is unstable to begin with and an un-level surface will allow the center of gravity of the load 

to shift more rapidly to the down side. Any movement caused by work being performed on the load could also cause the 

load to slip off a support, especially if it is not properly blocked or cribbed. 

Always take the time to adequately support an elevated piece of equipment when performing repairs or adjustments 

to prevent being crushed. Even a very small, quick adjustment such as tightening a bolt warrants using appropriate 

support methods when you are under raised equipment. Using suitable supports, such as cribbing and blocking under 

the raised tractor, in addition to turning the tractor off before dismounting could have prevented this fatal injury.
REPORT#: 15MI064 Page 6

Recommendation #3: When working under equipment, if wheels are in contact with the ground, block/chock these 

wheels to prevent equipment movement. 

Discussion: Blocking the wheels prevent the tires from rolling. Blocks and/or wheel chocks should be selected according 

to the equipment’s tire size, percent grade the equipment is being serviced on, the surface conditions and the vehicle’s 

weight. It is best to use two blocks/chocks on the weighted axle since the weighted axle keeps the tire on the ground 

against the block/chock. In this incident, the weighted axle was at the front wheels of the tractor which were still on the 

ground. If the block/chock is placed at the unweighted axle, the tire on the unweighted axle can ride up and over the 

block. Use blocks/chocks in pairs, one set at each tire. For most farm equipment even pine timbers will have sufficient 

strength to keep from crushing or rolling. Rolling can be a problem on the farm during field repair. MIFACE recommends 

4”x 6” blocking rather than 4” x 4” to minimize rolling. The 6" blocks also fit more jacks. See Attachment A for further 

information about cribbing and blocking equipment.

To learn more about selecting and positioning wheel chocking/blocking, an internet search revealed the following 

brochure from Monster Motion Safety: Wheel Chock Guidelines. 

Recommendation #4: When working alone, establish a check-in procedure/written plan to help assure prompt 

emergency assistance. 

Discussion: Agricultural workers, including farmers, regularly work alone on the farmstead. Therefore, it is important to 

establish an effective communication system for the individual who is working alone to contact other people who can 

provide emergency assistance. The frequency of checking in to another individual should be appropriate based on the 

hazards to which the isolated worker is exposed. The check-in procedure can be initiated by a family member or the

individual who is working alone and should be established based upon what is practical for the worksite circumstances. 

In agricultural settings, the availability of cell phone coverage should be established if that is the means of 

communication selected. 

Agriculture is not the only industry where workers work alone. Industries such as construction and utilities are 

establishing procedures and/or programs to monitor “lone workers”. Tucked into the MIOSHA Construction Safety 

Standard Part 1, General Rules is a rule covering First Aid, including first aid requirements for a remote location or single 

employee worksite (R 408.40132 (4)): Where a remote location or a single employee worksite exists, an employer shall 

provide a written plan that includes alternate methods of assuring available treatment for employees at a remote 

location or single-employee worksite. The plan shall be communicated to all affected employees. 

Although it may not have prevented his death, MIFACE recommends that any business develop a plan to establish a 

check-in procedure when an individual is working alone. Monitoring “lone workers” could prevent an injury from 

becoming a fatality.

REFERENCES

Weather Underground [2015]. Weather history for nearby weather station. The Weather Channel Interactive, Inc.

MIOSHA Standards cited in this report can be directly accessed from the Michigan Department of Labor and Economic 

Growth, MIOSHA website 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.
REPORT#: 15MI064 Page 7

• MIOSHA General Industry Safety Standard, Part 1, General Provisions Rule 408.10034(12) Machine Guards and 

Devices

• MIOSHA General Industry Safety Standard Part 38 (Hand and Portable Powered Tools), Rule 408.13838, Jacks, 

use.

• MIOSHA Construction Safety Standard Part 1 (General Rules), Rule 408.40132, Medical services and first aid.

ADDITIONAL RESOURCES

• Ohio State University, Agricultural Tailgate Safety Training, Agricultural Safety Program, Training Module: Chock 

and Block, Internet address: http://nasdonline.org/127/d001676/chock-and-block.html

• MIFACE Investigation Report #03MI053: Farm Owner Crushed Underneath Rotary Mower While Changing 

Blades and Untangling Wire Wrapped On Cutting Blades. www.oem.msu.edu/images/MiFACE/03MI053v1.pdf

• Washington FACE: Orchard Tractor Operator Dies When Run Over by Rotary Mower After Falling From Tractor.

https://www.cdc.gov/niosh/face/pdfs/13WA015.pdf

• Stoolmiller, Carson. Monster Motion Safety: Chocking Procedures – A Step-by-Step Guide for Maximizing Safety. 

https://monster-safety.com/chocking-procedures/ August 24, 2017. 

DISCLAIMER

Mention of any company or product does not constitute endorsement by the Michigan FACE program or the National 

Institute for Occupational Safety and Health (NIOSH). In addition, citations to websites external to NIOSH do not 

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is 

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

the publication date.

ACKNOWLEDGEMEMENT

The Michigan FACE Program would like to acknowledge the family of the deceased for providing assistance and 

information for this investigation. 
REPORT#: 15MI064 Page 8

Attachment A – Cribbing and Blocking

MIOSHA General Industry Safety Standard Part 38 (Hand and Portable Powered Tools), Rule 3839(4) addresses the use 

of “jacks”. The term “jack” refers to a portable lifting unit rather than a fixed unit (normally a hoist). To properly use a 

jack, its rated capacity must be permanently marked on the jack and must not be exceeded during a lift. The jack must 

be set on or against a firm foundation or blocking. If a jack, at the point of contact with the load, can slip, a wood block 

or nonslip device must be placed between the cap and the load. Importantly, after a load has been raised or moved, it 

shall be secured by cribbing, blocks or stands before work is started under the supported load (Refer to the standard for 

the other requirements for the use of jacks and their inspection).

Most jacks are designed to lift heavy objects, not support them. Proper use of a jack involves knowing the weight limit 

and proper placement of the jack. Once a jack lifts a heavy object, the object must then be supported by either a jack 

stand or cribbing. A “jack stand” normally refers to a metal adjustable support with a center post that adjusts and side 

stabilizers that hold the device straight. Cribbing is the process whereby blocks of wood are placed under the object to 

support it in an elevated position. Supporting elevated objects with jack stands or cribbing ensures stability of the object 

especially when work has to be performed under the object. Wood selected for blocking or cribbing should be solid, 

straight and free of major flaws such as large knots or splits and be free of any paint or finish because this can make the 

wood slippery, especially when it is wet.

Blocking timbers should be used to provide a foundation for heavy loads or jacks 

when the jack is not placed on a firm foundation. Most jacks are designed to lift a 

load straight up. This is why it is essential to assure that the surface the load is on 

is level. Often during field equipment repair operations, the surface is not firm or 

even. Blocking timbers should be placed so they rest evenly and firmly on the 

ground.

Cribbing should be used when the equipment must be supported at a height 

greater than blocking can provide. Cribbing involves placing timber in tiers that 

run in alternate directions. To place cribbing, raise the load and without placing 

yourself under the elevated load, place the cribbing under the load. (See Figure 2). 

Then lower the load onto the cribbing. If using a jack to raise the load, make sure 

the jack is on a firm foundation (use blocking timbers as required), raise the load 

to the maximum height the jack can safely lift to, place cribbing, then lower the 

load. 

Figure 2. Example of 

cribbing