Date of incident: September 2021
Notice of incident number: 2021170090004
Employer: Ranch

Incident summary
Two workers were installing a fence post in a rancher’s field. One worker was operating a tractor with a loader attachment that had a grapple bucket on it, and was using the bucket to press the fence post into the ground. The other worker, who had been steadying the post, was standing on the ground in front of the loader next to the post. The bucket fell off the tractor’s loader attachment and crushed the worker by the post, who sustained fatal injuries.

Investigation conclusions

Cause

• Grapple bucket fell off loader attachment and struck worker. The grapple bucket being used to press the fence post into the ground weighed about 655 kg (1444 lb.). It was only partially connected to the loader’s tool carrier. As the loader applied downward pressure to the top of the post, the bucket came free from the loader, flipped forward, and landed on the worker. The worker sustained fatal crushing injuries.

Contributing factors

• Lack of hazard identification and risk assessment. The tractor operator and the other worker originally planned to use a post pounder (a hammer powered by a hydraulic ram) to install the fence post. They discovered the fence post was too tall for the post pounder. Instead, they decided to use an implement on the tractor’s front loader attachment. They settled on the grapple bucket. The worker needed to stand next to the fence post to help stabilize it as the bucket was placed atop it. When the work plan changed from using the post pounder to using the grapple bucket, the firm did not ensure that a hazard identification or a formal or informal risk assessment was done that could have helped identify the hazards associated with the new plan. No control measures were put in place to address the related risks. The worker was exposed to the risk of being struck by the bucket, which is what happened when the bucket fell from the loader attachment.
• Locking mechanism engaged prematurely. At an unidentified point before the bucket was connected to the loader attachment’s tool carrier, the locking mechanism on the tool carrier had engaged. This prevented the tool carrier’s locking pins from connecting through the eyes of the locking lugs on the bucket. Thus, the bucket was not properly secured to the tool carrier.
• Checklist for verifying grapple bucket connection was not adhered to. The ranch had a copy of the operator’s manual for the tractor’s loader attachment. The manual includes a three-item list of ways to check that the bucket is securely connected: check visually from the cab that the locking mechanism is in the locked position, check visually from outside the cab that the locking pins on the tool carrier are in the locked position, and, using the controls in the operator’s cab, press the front of the bucket against the ground. The first check was performed, and the locking lever appeared to be in the locked position. The other two checks were not performed. The firm failed to ensure that the manufacturer’s instructions were followed.

Other health and safety issues

• Parking brake not engaged properly when operator left cab. After the incident the operator left the cab of the tractor to tend to the worker. While doing so, he heard the tractor moving toward his location. The operator had to quickly get out of the way and reach inside the tractor to put it in reverse, then shut it down using the ignition key. The tractor was not secured to prevent unintentional movement before the operator exited the cab. This was not a contributing factor in the incident.

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