Beyond the Minimum: Lessons from a Fatal Incident

What Happened

In June 2023, two people (Person A and Person B) were unloading a non-running 1950’s tractor from a trailer. Important points to include are:

• Both Person A and Person B had experience unloading tractors that did not run.
• There was a discussion and a plan was made prior to unloading the tractor.
• While the engine didn’t run, its manual steering and brakes seemed to work, and all of the tires were inflated.
• The trailer ramps were set up properly for the tractor’s wheel width.

Person A stood on the tractor to steer it, and Person B used a utility tractor and a chain to pull it off the trailer. As the utility tractor moved forward, the wheels of the 1950’s tractor slipped off the ramps. When this happened, Person A fell off the 1950’s tractor. Person B stopped the utility tractor when they heard a bang and felt slack in the chain. The 1950’s tractor kept moving, striking Person A and resulting in a fatal injury. It was also identified that the front tires were misaligned, causing it to veer to one side.

Corrective Actions After the Incident

Things the employer did to prevent a similar incident from happening again:

• They stopped the work and documented hazard assessments and hazard control measures for loading and unloading older model tractors.

Prevention Highlights

• Employers must have written hazard assessments and control reports that:
• Identify all existing and potential hazards
• Identify the measures taken to eliminate or control all identified hazards following the hierarchy of control
• Involve affected workers in the hazard assessment and control process