Failure to properly train employees and the use of older mobile equipment that lacks up-to-date safety features can be a lethal combination.
Employees using heavy equipment need to be thoroughly trained to operate these vehicles safely.
This is especially critical when heavy equipment of an older design is in use because these vehicles could have safety shortcomings when compared to those of more recent manufacture.
An Oregon State Fatality Assessment & Control Evaluation (FACE) program report on a March 2021 double fatality reveals that the incident was the direct result of a combination of these two safety issues.
Operator with 32 years of experience using 54K-pound excavator
On March 12, 2021, a heavy equipment operator was using a 2010 John Deere 225D LC tracked excavator at an Oregon ranch to build an access road across a small creek and prepare the site for a new horse barn. The excavator weighed 54,000 pounds.
The operator had 32 years of experience with his employer, a holding company that provided heavy equipment to operators, sold farm equipment and provided other related services. He was the only employee from the holding company who was on site.
An independent contractor hired by the ranch owner to act as manager was also working in the area along with another ranch employee.
Engine running, bucket up, lunch box over controls
The ranch manager and worker stopped by the worksite and found the equipment operator was outside of the excavator’s cab, which was turned about 30 degrees toward the right track, with the engine running and the bucket raised about 1 foot off the ground. The operator was climbing back into the excavator when the ranch manager approached him.
While they talked, the operator was standing on the excavator’s track. When they finished talking, the ranch manager turned to walk away when the excavator suddenly began to move in reverse with the operator still standing on the track.
Investigators believe that as the operator re-entered the cab to turn the excavator off, his coat hooked on the pilot control stop bar that kept the machine from moving. When the operator’s coat hooked on the bar, it shifted it, allowing the machine to move.
What caused the excavator to move in reverse? The operator’s 20-pound lunchbox had been wedged into a space just above the control levers. Its weight caused it to slowly drift down onto the levers, which caused it move as soon as the pilot control stop bar shifted. The excavator had two speeds: slow and fast. It was set to fast at the time of the incident.
An Oregon OSHA investigation later noted that the machine moved about 25 feet in a matter of seconds.
Ranch manager crushed in rescue attempt
The equipment operator lost his balance and fell toward the center of the excavator, ending up under the track on the opposite side of the cab door.
As the excavator began to move, the ranch manager looked back in time to see the equipment operator fall between the tracks. He rushed over to try to pull the equipment operator away and was caught underneath the same track.
Both men were crushed by the weight of the machine.
The other ranch worker was initially looking in the opposite direction. When he saw what had occurred, he ran over to stop the excavator. He managed to reach in, raise, and lock the pilot control stop bar, ceasing the excavator’s movement. The worker was unable to get the equipment operator and the ranch manager out from under the excavator’s track. Later, the excavator had to be jacked up to remove their bodies.
Both men were pronounced dead at the scene from crushing injuries.
Employer didn’t have formal safety training for employees
FACE program investigators found that the holding company the equipment operator worked for only had an informal training program. It also didn’t have a comprehensive safety and health plan.
The training policy, such that it was, involved starting new operators to work in a safe area with smaller equipment until they were proficient. They could work their way up to using larger equipment. More experienced operators would train newer operators.
None of this informal instruction involved reading equipment safety manuals.
As for the ranch manager, he was the owner and operator of his company. His wife, the office manager, was the only other employee. There was no information available regarding any safety or training programs he may have had.
Older excavator was missing safety features of current designs
The John Deere excavator was manufactured in 2010. Investigators found no malfunctions that would have contributed to the fatality.
However, there was an approximately 20-pound lunch box wedged between the front window and directional control levers. The weight of the lunch box depressed the levers, causing the machine to travel when the pilot control stop bar was released. Exactly how or why this occurred wasn’t determined.
This bar is located near the cab exit and shuts off the hydraulic pressure to all control valves. When the lever is in the locked position the machine won’t move even if the controls are accidentally depressed, although unintentional movement of the bar could cause the controls to be activated.
FACE program investigators outlined three ways employers can avoid a similar incident:
1. Have a formal operator training program
A formal training program should include specific information on the operation of the equipment, including the manufacturer’s instructions, a review of the equipment manual and training on employer-specific equipment policies.
An operational evaluation of the operator’s performance should also be incorporated into the program, including regular and consistent use of safety features, especially when exiting and entering the cab.
Annual refresher training should also be completed to confirm that safe operating practices are still being used. A formal recertification process should be completed every three years by having the operator review safe practices and demonstrate proficiency with the equipment.
2. Replace older equipment, when possible
Older equipment, such as the excavator used in this incident, should be replaced with newer equipment that has advanced safety features, when possible.
Equipment of newer manufacture has “prevention through design changes and equipment engineering controls” that are meant to prevent the kind of incident described above.
Some examples include:
- sensors that automatically lock out controls when weight is removed from the seat
- pilot control stop levers that are built specifically to be rotated up and out of the way in order to exit the cab, and
- emergency shut-off switches that are easily accessible from the ground in addition to larger pilot control levers.
3. Ensure manufacturer safety instructions are followed
In this incident, the manufacturer of the excavator had a warning label on the cab window reminding operators that the bucket should always be lowered to the ground and the pilot control stop bar applied when parking or leaving the machine.
There was also a manufacturer’s manual in the machine that had detailed instructions for safe operation and best practices.
“By following the manufacturer’s instructions, the inadvertent activation of the machine that caused the fatality may have been prevented,” the FACE program report states.
