to a tractor runs him over.On a morning in April 2013, a Washington-state orchard supervisor left the orchard to pick up tractor parts.Before leaving, he asked a fellow worker to perform a task using a working tractor. When the supervisor returned at 10:00 a.m., he discovered that worker was severely injured.At some point during the time the supervisor was gone, the employee had been run over by the mower attachment after falling off the tractor, suffering large cuts on the back of his head and arms.A subsequent investigation conducted by the Washington State Fatality Assessment and Control (WA FACE) found the following:The victim was using the tractor and mower attachment to cut the grass between rows of pear trees. The incident was not witnessed, but investigators believe that it is most probable that he fell when he attempted to dismount the tractor to retrieve his hat that may have been knocked off by a low hanging branch.He likely either failed to put the tractor in neutral when he stopped, causing the tractor to lurch forward when he removed his foot from the clutch pedal, or inadvertently moved the gear selector lever out of neutral as he stood up to dismount the tractor.In either scenario, it is assumed that the sudden or unexpected movement of the tractor caused him to fall to the ground between the tractor and the mower. As the tractor continued to move forward, the victim’s upper body was run over by the 1740 lb. mower. He was pronounced dead at the scene.WA FACE also discovered during the investigation that the ignition on the tractor had been bypassed and a starter switch had been added, allowing the machine to be started while in gear. Manufacturer specifications only allowed the tractor start and stop using the key. However, investigators could not determine if the modification played any part in the accident.The agency, which operates under the Washington State Department of Labor & Industries’ Safety & Health & Research for Prevention (SHARP), provided the following recommendations to prevent future incidents:Train operators to always shut down tractors safely before leaving the driver’s seat. Ensure that they follow safety guidelines through frequent retraining and spot checks.Train operators to always mount and dismount tractors in a safe manner by using all steps and handholds available, and maintaining three points of contact.Keep clear of obstacles, such as low hanging branches, to the extent possible when operating a tractor with or without attachments.Consider using tractors equipped with operator presence sensing (OPS) technology or other interlocks that will lock out the powertrain and PTO if the operator leaves the driver’s seat.According to WA FACE, the employer had a written safety program and monthly meetings. Tractor safety training was provided on an annual basis. In addition, the victim had been provided and signed-off on written tractor safety material twice since beginning employment.Details of the entire investigation can be found on the NIOSH website.