Investigation # 97WV041-01
Release Date: December 15, 1997

Bulldozer Operator/Logger Crushed by Crawler Bulldozer After Pulling Logging Truck From Mud on Logging Road in West Virginia

SUMMARY

On February 26, 1997, a 56-year-old self-employed male crawler bulldozer operator/logger (the victim) died of injuries sustained when he was run over by right track of a bulldozer.  Just before the incident, the victim had used the bulldozer to pull a fully loaded log truck out of the mud.  Once the log truck was free and while the bulldozer was running, the victim exited the bulldozer operator's position.  The bulldozer, with blade in raised position, accelerator wide open and without a driver,  moved in reverse down a slight grade until it rested against the cab of the log truck.  Investigative information suggests that because the transmission control safety lever (neutral lock lever) was broken, the operator could not lock the machine into neutral. This allowed the transmission to slip from neutral into reverse causing the bulldozer to move suddenly backwards.  Neither the log truck driver, seated in the cab of the log truck nor a logger loading logs nearby saw the incident as they were engaged in other activities at the time.  Immediately following the incident, the men responded and saw that the victim had sustained traumatic amputation of the lower extremities and crushing injuries.  They called emergency medical services and police for assistance.  The local EMS transported the victim to a local hospital where he was pronounced dead.  The coroner estimated the time from injury to death to be between zero and three minutes.  The WV FACE Investigator concluded that to reduce the likelihood of similar occurrences, employers, including the self-employed, should:

ensure that machines used for any operation (e.g. logging operations) are maintained in serviceable condition;

ensure that machines used for any operation (e.g. logging operations) are not left unattended unless all precautions necessary to prevent motion have been taken;

develop, implement, and enforce a written safety program which includes, but is not limited to, training in hazard identification, avoidance, and abatement.
 

INTRODUCTION

On April 10, 1997, the West Virginia FACE Program Coordinator/Investigator reviewed death certificates received by the WV FACE Program and noted that on February 26, 1997, a 56-year-old self-employed bulldozer operator/logger was killed on a logging site when he was run over by the right track of the crawler bulldozer. On August 13, 1997, the WV FACE Investigator traveled to the county where the incident occurred and met with the police officer who had made the initial onsite investigation in February.  The police report, police photographs, death certificate, and medical examiner's report were obtained during the course of the FACE investigation.  Contact was made with the OSHA compliance officer who also investigated the incident.  An operator's manual for the type of machine involved in the incident was obtained from the manufacturer, John Deere 450-C Operator's Manual, John Deere Dubuque Works OM-T71338 Issue HO.(1)

The victim was self-employed and held Certified Logger status in West Virginia.  [Note: The Logging Sediment Control Act of West Virginia (1992) requires that each timbering operation in West Virginia must be supervised by a certified logger.  To become a certified logger, an individual is required to successfully complete training and pass a test for best management practices (a soil erosion prevention plan) and chain saw safety, and possess a current first-aid card.(2)]  The victim had been working in the logging business for approximately thirty years.  No other company-specific information or past employment information was obtained.

INVESTIGATION

On the morning of February 26, 1997, the victim and another logger had fully loaded a log truck with logs they had cut on a strip-mine site. A truck driver, employed by the company who had purchased the logs, was hauling them out on a rough logging road when he became stuck in a muddy dip in the road.  The victim connected a steel pull-cable between the bulldozer and the logging truck and pulled the log truck forward out of the dip. It is estimated that approximately 50 feet of steel cable stretched between the bulldozer and the truck. The weather was clear and dry, and the temperature was 40 degrees Fahrenheit the day of the incident; however, the rough logging road was wet and muddy from previous snow and rain.  After pulling the truck out of the dip, the victim exited the bulldozer.  The bulldozer was running and the blade was in the raised position when the operator exited.  The bulldozer went into reverse and continued to move in reverse until it struck the cab of the log truck.  The tracks continued to move and dig until the bulldozer was turned off.  At some point in the sequence of events the operator had been run over by the right track and/or caught in the pull cable and suffered traumatic amputation of the lower extremities and crushing injuries.

Information from the police report indicated that an OSHA compliance officer visited the site immediately after the incident, inspected the site, and examined the crawler bulldozer.  The bulldozer was not available to the WV FACE Investigator, therefore State Police Report #12655 was used to detail findings related to the bulldozer.  The crawler bulldozer operated by the victim was a 1982 Model 450-C John Deere, Serial Number 383464T (see Figure 1). The transmission control safety lever (neutral lock lever), which must be engaged in order to lock the transmission in neutral, was broken.  When the transmission control safety lock (neutral lock lever) is engaged, the machine is in a stable neutral position, and the operator must manually disengage the neutral lock in order to shift the machine from neutral to an operating range.  On this occasion, because the safety control lock was broken and thus could not be engaged, the victim may have inadvertently hit the H-L-R lever (this lever is located next to the gear shift lever and controls the range which can be placed in high, low, reverse or neutral) as he exited the machine and knocked it from neutral into reverse range. An alternative explanation may be that the victim inadvertently hit the accelerator controls as he exited the machine and vibration caused by the high engine speed may have caused it to "jump" shift into reverse without the operator touching the controls (see Figure 2 for instrument panel detail).  When the machine was started after the incident, the accelerator was wide open and the engine ran at approximately 2500 RPM, the bulldozer brake lock was not engaged, and the blade was in the raised position.

The truck driver, who was seated in the cab of the logging truck, and another logger who was loading logs nearby did not see the victim exit the bulldozer nor did they see how he became entangled in the track and/or the pull cable.  They heard and saw the bulldozer hit the cab of the truck and went immediately to investigate.  It was clear that the victim had sustained fatal injuries, and they immediately called for emergency medical services and police assistance.    After assistance arrived, the victim was transported to the local hospital emergency room where he was pronounced dead.  The medical examiner's report indicated that death occurred immediately following the injuries.

CAUSE OF DEATH

The medical examiner's report listed the immediate cause of death as hemorrhagic shock.

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers, including the self-employed, should ensure that machines used for any operation (e.g. logging operations) are maintained in serviceable condition.

Discussion: The victim, who was self-employed, used a 15-year-old bulldozer which had a broken, inoperable, transmission control safety lock (neutral lock), a primary safety feature.  Although self-employed persons are not required to comply with OSHA regulations, the WV FACE Program uses appropriate OSHA regulations to formulate recommendations.  OSHA Regulation 29 CFR 1910.266(f)(1)(I)(ii) requires that machines used in logging be maintained in serviceable condition and that they be inspected at the beginning of each work shift.  Defects or damage shall be repaired or the unserviceable machine shall be replaced before work is commenced.(3)  The John Deere 450-C Operator's Manual warns in their written safety rules not to operate the crawler in any unsafe condition.  In this incident, the bulldozer was not in serviceable condition, and the victim may have failed to grasp the degree of hazard present.  Inspecting this machine prior to its use, recognizing the attendant risk of the broken transmission control safety lock (neutral lock), and removing the bulldozer from service may have prevented this incident.

Recommendation #2: Employers, including the self-employed, should ensure that machines used for any operation (e.g. logging operations) are not left unattended unless all precautions necessary to prevent motion have been taken.

Discussion: The victim exited the bulldozer while it was running.  This is standard practice among operators.  The manufacturers of crawler bulldozers recommend that the following procedures be followed prior to the operator dismounting the machine:

Stop the machine on level ground and reduce engine speed.
Move H-L-R lever to neutral.
Engage the neutral lock.
Push down the brake pedal.  Engage the brake lock.
Lower all equipment to the ground.
The John Deere Operator Manual advises the operator to shut off the engine.(1)
CFR 1910.266(f)(2)(x) requires that before the operator leaves the machine, it shall be secured as follows: a) the parking brake or brake locks shall be applied; b) the transmission shall be placed in the manufacturer's specified park position; and c) each moving element such as, but not limited to, blades, buckets, saws and shears shall be lowered to the ground or otherwise secured.  If a combination of these procedures had been followed, the fatal injury probably would have been prevented.

Recommendation #3: Employers, including the self-employed, should develop, implement, and enforce a written safety program which includes, but is not limited to, training in hazard identification, avoidance, and abatement.

Discussion: The evaluation of tasks to be performed at the worksite form the basis for the development, implementation, and enforcement of a safety program.  The key elements of the program should include, at a minimum, training in hazard identification and the avoidance and abatement of these hazards.  In this incident, the victim was killed when he became entangled in the bulldozer tracks and possibly caught by the pull cable.  Hazards created by damaged or inoperable equipment should have been recognized and addressed to ensure maximum safe working conditions.

REFERENCES

John Deere 450-C Operators Manual, John Deere Dubuque Works OM-T71338 Issue HO.

West Virginia Sediment Control Act, 1992.

Office of the Federal Register: Federal Register, Vol. 59, No. 196, 29 CFR 1910.266, p. 51746, Wednesday, October 12, 1994.

FATALITY ASSESSMENT AND CONTROL EVALUATION PROGRAM

The WVU Center for Rural Emergency Medicine, through a contract with the West Virginia Department of Health and Human Resources, conducts investigations on the causes of work-related fatalities within the state.  The goal of this program is to prevent future fatal work-place injuries.  West Virginia FACE intends to achieve this goal by identifying and studying the risk factors that contribute to workplace fatalities, by recommending intervention strategies, and by disseminating prevention information to employers, employees, trade associations, unions, equipment manufacturers, students, teachers, and others with an interest in workplace safety.

To contact West Virginia State FACE program personnel regarding State-based FACE reports, please use information listed on the Contact Sheet on the NIOSH FACE website. Please contact In-house FACE program personnel regarding In-house FACE reports and to gain assistance when State-FACE program personnel cannot be reached.

---

Free Consultation

---