Worker fatally injured when tractor rolled over
Date of incident: October 2022
Notice of incident number: 2022186420030
Employer: Fruit producer
Incident summary
At a cherry orchard, a worker was operating a farm tractor with a trailing tire implement (a large, rock-filled tire) attached to the back for grading roads. The worker was driving up a sloped embankment when the tractor rolled over. The worker was thrown from the tractor and sustained fatal injuries.
Investigation conclusions
Cause
- Tractor with improperly attached implement rolled over. The worker was operating the tractor in an area of the orchard with a steep embankment. While the worker was likely attempting a U-turn, loose soil built up in front of the trailing tire implement that had been improperly chained to the back of the tractor. The trailing tire implement became embedded in the ground, which caused the tractor’s front end to lift and slide down the embankment. The tractor flipped 270°, and the worker was thrown from the tractor.
Contributing factors
- Seat belt and rollover protective structure not used. The tractor was factory fitted with a seat belt and a rollover protective structure (ROPS), which are designed to be used together to prevent serious injury or death to the operator should a rollover occur. On the day of the incident, the seat belt was not fully operational, and therefore the worker was not wearing it when the incident occurred. In addition, the ROPS was not deployed as intended, so there was no survival zone created when the tractor rolled over.
- Inadequate supervision. On the day of the incident, supervision was ineffective at the workplace. No one was monitoring the worker, who was operating a tractor with an improperly attached trailing tire implement, a non-functional seat belt, and a non-operational ROPS. The employer could have created a system to make sure that the worker was reminded to use the seat belt and the ROPS; however, there was no supervisory oversight related to these items. Effective supervision should have detected and corrected these deviations from the employer’s safety manual, the manufacturer’s recommendations, AgSafe (a safety association for farm employers and farm workers in B.C.) guidance, and the requirements of the Occupational Health and Safety Regulation.
- Lack of working alone program. The employer did not have a working alone program, which should have been part of the occupational health and safety program for work in the orchard. On the day of the incident, the worker was last heard from at 13:00 and was not located until after 23:00. Proper use of a working alone program would have alerted the employer that something had happened to the worker much sooner.
- Lack of hazard identification and risk assessment. The grading of roads was a necessary and foreseeable activity at the workplace, but the employer had not completed any hazard identification or risk assessment for this task. In addition, a slope assessment had not been completed for the orchard. A slope assessment would have identified the significant slope change in the northwest corner of the orchard — where the incident occurred — and would have identified that area as posing a risk of rollover for mobile equipment. On the day of the incident, there was no direction from the employer on where the tractor could safely operate at the workplace.
2021-04-22 20:42:33