INTRODUCTION
On May 23, 1994, a 52-year-old part-time farmer died when
he was crushed by an overturned pick-up truck. On May 24, the
Kentucky FACE investigator read of the fatality in the newspaper.
On June 6, 1994, two weeks following the incident, the FACE investigator,
accompanied by a Traumatic Farm Injury Surveillance in Kentucky
(TFISK) registered nurse, traveled to the scene. The witness,
the county coroner, a neighbor, and the victim's widow were interviewed.
The scene, tractor, trailer and truck were photographed. Photographs
taken by the deputy coroner were also reviewed.
The victim, serving his second term as county jailer, also worked
as a part-time farmer maintaining an 87 acre farm about 6 miles
from town. He raised tobacco and 30 head of cattle. He had lived
and worked on the farm for 15 years after retiring from the Federal
Bureau of Alcohol, Tobacco and Firearms. He had borrowed the neighbor's
tractor several times in the past and had used similar procedures
to transfer the tractor to his farm, approximately 2.5 miles away.
The victim had not had any previous farm injuries and was considered
to be a farm safety advocate. He had owned the 1993 Chevrolet
1500 pick-up truck for 10 months. This was the first time this
particular truck was used in this procedure.
INVESTIGATION
The victim and his neighbor were preparing to load the 1976 International
Harvester Farmall 140 tractor onto a double axle 8' x 20' 38"
high flat bed trailer at 5:00 pm the day of the incident. The
victim was to transport the witness and his tractor to victim's
farm where the witness was to plow recently planted tobacco fields.
This procedure had been used previously so that the neighbor would
not have to drive the 2.5 miles on public roadways. The truck
and trailer were parked on a gravel, single lane road with a nine
degree downward slope. Along the right side of the road was a
brush filled earthen bank four feet high sloping 45 degrees downward
toward the road. The afternoon was warm and dry. The victim was
about an hour late for the scheduled pick up and transfer of the
tractor.
At about 5:10 pm the victim arrived at the neighbor's farm to
transfer the tractor (plows attached) to plow two tobacco patches.
He parked the 1993 Chevrolet four wheel drive automatic with trailer
attached and turned the engine off. The truck was headed down
hill. The truck was in 'park'. The emergency brake was not set.
On the right of the truck was an earthen bank. The victim positioned
himself on the trailer in order to guide the Farmall 140 tractor
onto the trailer. The trailer supports were not down. No chocks
were used at the wheels. As the witness began to drive the tractor
onto the trailer, the truck and trailer began to roll down the
sloping gravel road. Noticing the trailer move, the victim jumped
off the trailer and ran to the driver side door in order to stop
the vehicle. The truck, steering wheel locked, headed for the
bank on the right side of the road. It rolled 65 feet and turned
over onto the victim before he was able to get in and apply the
brake. The truck came to rest on its side with its front angled
across the road pinning the victim under the truck's left side.
The bed of the truck, just behind the driver side door, smashed
the victim's lungs. It appears the force of the trailer pushing
the truck up the bank caused the truck to roll over.
The neighbor stopped the tractor and ran to the victim. Realizing
he needed help, (the Farmall 140 was too small to right the truck),
the witness went to a neighboring farm to summon help. The 55
year old witness with emphysema ran about 3 tenths of a mile to
use the neighbor's phone. The EMS was notified. Fire department
personnel arrived at the scene at 5:58 pm. Noting no pulse, respirations
or blood pressure, the coroner was notified and arrived at the
scene at 6:22 pm. The coroner pronounced the victim dead and estimated
time of death at 5:41 pm.
CAUSE OF DEATH
The coroner listed the cause of death as traumatic suffocation
due to truck overturn. An autopsy was not performed.
RECOMMENDATIONS/DISCUSSION
Recommendation #1: The trailer supports (stabilizers) should
be used when loading and unloading equipment.
Discussion #1: The tail end support jacks were not used
in this case. Evidence at the scene suggests that the rear end
of the truck was lifted off the ground by the weight of the tractor
as it went onto the trailer. This freed the front truck wheels
to roll. If the tail end jack were engaged, this would transfer
the weight to the ground directly below the tractor. As it happened,
the weight was transferred by the fulcrum of the trailer wheels
to the truck hitch. This lifting action allowed the truck to roll
forward.
Upon inspection of the trailer, it was noted that the support
jacks were operable. However. they lacked the adjustability to
account for variations in surface terrain. The support jacks should
have variable height positions to allow for their use in areas
that are not flat.
With the weight of the tractor on the rear of the trailer the
bed of the pick-up was lifted. This would not be the case with
support jacks.
Recommendation #2: Chocks should be used to prevent vehicle
roll.
Discussion #2: Neither the trailer nor the truck had chocks
in front of the wheels. With the sloping grade, chocks should
have been in place prior to loading the tractor. This may have
prevented the forward motion of the truck.
Recommendation #3: Trailers should be equipped with multiple
height adjustment stabilizers or fixed on ramp boards with angle
brackets to transfer the load directly downward.
Discussion #3: The trailer did not have multiple adjustment
jack posts. Had there been various height settings possible, the
victim may have been able to stabilize the rear end of the trailer
on the uneven gravel thus preventing the lifting action of the
weight of the tractor. A better alternative would be movable ramps
equipped with permanent angle brackets which come into contact
with the ground when they are in use.
Recommendation #4: The terrain should be evaluated prior
to starting any operation.
Discussion #4: The victim, who was late for the pick up,
did not fully evaluate the situation and conditions or anticipate
the truck roll. Careful consideration of the terrain may have
resulted in trying to load the tractor at a different place on
the farm.