Investigation Reports
The Oregon Fatality Assessment and Control Evaluation (OR-FACE) team has written in-depth investigation reports that examine contributing factors and lessons learned from selected cases. We hope that you will use these investigation reports and other OR-FACE resources for educational purposes, to help save the lives of other workers in similar situations. Investigation reports cover incidents in industries including agriculture, construction, logging, transportation and more.
Elements of an OR-FACE investigation
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Type of industry involved
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The victim's age, sex, occupation
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The task(s) the victim was performing
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The tools or equipment the victim was using
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The energy exchange resulting in fatal injury
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The working environment
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Number of employees in the company
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Company safety program
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The role of management in controlling how these factors interact
OR-FACE is a research program; investigators do not enforce compliance with state or federal occupational safety and health standards and do not determine fault or blame.
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Explore investigation reports
Agriculture
2021-02 Farmworker heat-related fatality (pub Oct 2023)
2020-02 Farmworker crushed in ATV rollover during herbicide application on a hillside (pub Sept 2021)
2017-07 Farm mechanic died after torch-cutting explosion – (pub Mar 2019)
2013-05 Vineyard worker killed in fall from trailer (pub Dec 2014) (rev Feb 2015)
2006-25 Ranch worker killed by pressurized water striking eye (pub Dec 2007)
2004-07 Nursery laborer killed in skid-steer loader (pub Aug 2005)
2003-33 Farm driver overturns truck in irrigation ditch and drowns (pub Aug 2005)
2005-28 Bulldozer movement kills operator standing on track (pub May 2006)
2004-23 Ranch hand killed by bulldozer while logging (pub May 2006)
2003-19 Farmer is killed when he falls beneath moving combine (pub Jul 2004)
Construction
2021-01 Heavy Equipment Operator and Rancher Crushed by Excavator (pub May 2023)
2018-40 Newly hired lighting technician electrocuted while working night shift (pub Oct 2020)
2018-30 Pipefitter Struck by Pressurized Pipe and Killed (pub Jul 2020)
2018-08 Skid-steer operator crushed while controlling the skid-steer from outside the cab (pub Oct 2019)
2016-16 Construction worker killed when trench collapsed (pub Oct 2018)
2015-12 Construction worker died after falling 20-25 feet from pump-jack scaffold (pub Dec 2017)
2015-02 Crane operator killed by falling steel beam (pub Jan 2016)
2013-27 Collapsed roof trusses kill carpenter foreman (pub Jul 2014)
2008-01 Mechanic killed by excavator bucket during maintenance (pub Sep 2012)
2007-17 Highway worker crushed by swinging backhoe boom (pub Jan 2009)
2006-03 Novice drywall installer dies in 7-foot fall from scaffold (pub Jun 2007)
2005-24 Excavation worker killed by flying rigging when hook fails (pub Aug 2006)
2003-40 Effort to clear rock jam in operating rock crusher fatal (pub Apr 2005)
2003-10 Home construction worker falls down elevator shaft (pub Aug 2004)
2003-08 Hispanic laborer drowns after falling into landscaping pond (pub Jul 2004)
2003-15 Construction worker dies when he leans out of the protective cage of a skid steer forklift (pub Jul 2004)
2003-16 Load of lumber shifts and falls on construction worker killing him (pub Jul 2004)
Falls
2013-05 Vineyard worker killed in fall from trailer (pub Dec 2014) (rev Feb 2015)
2007-57 Temporary mill worker killed in fall down manlift shaft (pub Sep 2010)
2006-03 Novice drywall installer dies in 7-foot fall from scaffolding (pub Jun 2007)
2005-38 Window cleaner killed in fall due to unsecured line (pub Oct 2006)
2005-18 Temporary mill worker dies in fall from tower catwalk (pub Oct 2006)
2003-10 Home construction worker falls down elevator shaft (pub Aug 2004)
2003-01 Roofer’s family member helping at worksite dies after falling through skylight (pub July 2004)
Fishing, crabbing and boating
2016-07-1 Crab fishing vessel capsizes and one crew member drowns (pub Jul 2020)
2016-06-1, 2, 3 Crab fishing vessel capsizes and drowns three crew members (pub May 2020)
2003-39 Worker is thrown from cab of crane and is crushed (pub Jul 2004)
Logging and forestry
2022-01 Wildland Firefighter struck and fatally injured by hazard tree (pub Jun 2024)
2014-42 Forestry worker in vehicle killed from timber falling activity (pub Jan 2017)
2014-01 Driver killed when ejected from logging truck (pub Mar 2015)
2011-50 Timber faller killed while working under a hung tree limb (pub Jul 2013)
2008-07 Rigging slinger killed by swinging log in yarding turn (pub Apr 2011)
2006-24 Logger killed under rigging when carriage drops (pub Apr 2011)
2006-19 Young logger killed when yarder topples during setup (pub Sep 2009)
2006-14 Log truck driver killed when brakes fail on steep road (pub Sep 2008)
2006-01 Mechanic killed pouring gasoline on fire (pub Sep 2008)
2006-09 Logger killed by 41-foot pole sliding down steep hill (pub Oct 2007)
2005-39 Logging worker killed while riding on step of skidder (pub Dec 2007)
2004-21 Truck driver crushed by front-end loader in mill yard (pub Dec 2006)
2004-52 Logger killed by swinging tree in yarding operation (pub Aug 2006)
2004-23 Ranch hand killed by bulldozer while logging (pub May 2006)
2003-29 Operator killed when bulldozer slides off logging road (pub Jan 2006)
2003-06 Logger killed by falling sheave when yarder tower collapses (pub Oct 2005)
2003-07 Logger killed as skyline cable whips free of slash pile (pub Apr 2005)
Machine-related
2023-01 Lumber mill employee fatally struck by forklift (pub Oct 2024)
2019-01 Two Workers Killed in Boom Lift Rollover (pub August 2023)
2021-01 Heavy Equipment Operator and Rancher Crushed by Excavator (pub May 2023)
2020-10 Forklift Operator Crushed by Full Pallet of Soft Drink Cans (pub Dec 2020)
2018-08 Skid-steer operator crushed while controlling the skid-steer from outside the cab (pub Oct 2019)
2017-22 Maintenance Mechanic Crushed Working Inside of a Vertical Storage Machine (pub Aug 2019)
2018-29 Rubber equipment operator died after his head was caught between bars of operating machinery (pub Jun 2019)
2017-07 Farm mechanic died after torch cutting explosion (pub Mar 2019)
2013-05 Vineyard worker killed in fall from trailer (pub Dec 2014) (rev Feb 2015)
2013-08 Contract sanitation worker killed cleaning meat blending equipment (pub Dec 2014) (rev Dec 2014)
2012-18 Experienced journeyman machinist killed while operating an engine lathe (pub Apr 2014)
2011-16 Millwright fatality involving a hydraulic accumulator (pub Dec 2013)
2008-01 Mechanic killed by excavator bucket during maintenance (pub Sep 2012)
2007-57 Temporary mill worker killed in fall down manlift shaft (pub Sep 2010)
2007-17 Highway worker crushed by swinging backhoe boom (pub Jan 2009)
2005-43 Mill worker killed by flying chunk of wood from chipper (pub Dec 2007)
2006-26 Machine operator dies after head crushed in machine (pub Oct 2007)
2006-06 Worker killed when jacket pocket activated machinery (pub Jun 2007)
2006-05 Mechanic killed when collar caught on PTO driveline (pub Nov 2006)
2005-28 Bulldozer movement kills operator standing on track (pub May 2006)
2004-23 Ranch hand killed by bulldozer while logging (pub May 2006)
2005-08 Mechanic killed while inspecting masonry stacker machine (pub Apr 2006)
2005-05 Operator crushed while repairing running machine (pub Mar 2006)
2004-15 Fabricator killed by ruptured hydraulic press fitting (pub Mar 2006)
2005-07 Technician crushed when aerial platform lift engaged (pub Feb 2006)
2004-37 Janitor using propane buffer killed by carbon monoxide (pub Feb 2006)
2003-29 Operator killed when bulldozer slides off logging road (pub Jan 2006)
2004-05 Machine operator electrocuted while shoveling pellets (pub Jan 2006)
2003-06 Logger killed by falling sheave when yarder tower collapses (pub Oct 2005)
2004-04 Parked forklift crushes operator against semi-trailer (pub Sep 2005)
2004-10 Forklift crushes operator working underneath on starter (pub Sep 2005)
2004-07 Nursery laborer killed in skid-steer loader (pub Aug 2005)
2003-40 Effort to clear rock jam in operating rock crusher fatal (pub Apr 2005)
2004-03 Sawmill worker crushed during debarker maintenance (pub Mar 2005)
2003-18 Auto salvage worker killed by unsecured car on transporter (pub Aug 2004)
2003-39 Worker is thrown from cab of crane and is crushed (pub Jul 2004)
2003-19 Farmer is killed when he falls beneath moving combine (pub Jul 2004)
2003-15 Construction worker dies when he leans out of the protective cage of a skid steer forklift and is crushed (pub Jul 2004)
2003-16 Load of lumber shifts and falls on construction worker killing him (pub Jul 2004)
Transportation
2014-01 Driver killed when ejected from logging truck (pub Mar 2015)
2013-05 Vineyard worker killed in fall from trailer (pub Dec 2014)
2010-06 Truck driver crushed between semi-trailer and loading dock (pub Mar 2013)
2007-11 Salesman killed when forklift falls off truck loading ramp (pub Oct 2009)
2006-14 Log truck driver killed when brakes fail on steep road (pub Sep 2008)
2006-44 Young warehouse worker killed by backing forklift (pub Apr 2008)
2005-39 Logging worker killed while riding on step of skidder (pub Dec 2007)
2004-21 Truck driver crushed by front-end loader in mill yard (pub Dec 2006)
2003-29 Operator killed when bulldozer slides off logging road (pub Jan 2006)
2004-07 Nursery laborer killed in skid-steer loader (pub Aug 2005)
2003-33 Farm driver overturns truck in an irrigation ditch and drowns (pub Aug 2005)
2003-32 Vehicle strikes utility worker in short-duration work zone (pub 2004)
2003-19 Farmer is killed when he falls beneath moving combine (pub Jul 2004)
Young workers
2006-44 Young warehouse worker killed by backing forklift (pub Apr 2008)
2006-09 Logger killed by 41-foot pole sliding down steep hill (pub Oct 2007)
2006-03 Novice drywall installer dies in 7-foot fall from scaffolding (pub Jun 2007)
2004-07 Nursery laborer killed in skid-steer loader (pub Aug 2005)
2003-33 Farm driver overturns truck in an irrigation ditch and drowns (pub Aug 2005)
2004-03 Sawmill worker crushed during debarker maintenance (pub Mar 2005)
2003-20 Young camp counselor killed when cannon bursts to pieces (pub Aug 2004)
2003-01 Roofer’s family member helping at worksite dies after falling through skylight (pub Jul 2004)
Hispanic workers
2020-02 Farm worker crushed in ATV rollover during herbicide application on a hillside (pub Sept 2021)
2017-07 Farm mechanic died after torch cutting explosion (pub Mar 2019)
2013-05 Vineyard worker killed in fall from trailer (pub Dec 2014) (rev Feb 2015)
2013-08 Contract sanitation worker killed cleaning meat blending equipment (pub Dec 2014)
2006-24 Logger killed under rigging when carriage drops (pub Apr 2011)
2007-57 Temporary mill worker killed in fall down man lift shaft (pub Sep 2010)
2006-25 Ranch worker killed by pressurized water striking eye (pub Dec 2007)
2006-3 Novice drywall installer dies in 7-foot fall from scaffold (pub Jun 2007)
2005-28 Bulldozer movement kills operator standing on track (pub May 2006)
2004-04 Parked forklift crushes operator against semi-trailer (pub Sep 2005)
2003-33 Farm driver overturns truck in an irrigation ditch and drowns (pub Aug 2005)
2004-04 Hispanic Laborer drowns after falling into landscaping pond (pub Jul 2004)
Fires and explosions
2006-01 Mechanic killed pouring gasoline on fire (pub Sep 2008)
2003-21 Worker killed in wood-dust fire sparked by faulty fuse (pub Feb 2006)
2003-22 Shipyard welder ignites hydraulic fluid and is fatally burned (pub Jul 2004)
Permit-required confined space
2004-02 Mechanic dies from lack of oxygen in transport tank (pub May 2005)
Workzone
2007-17 Highway worker crushed by swinging backhoe boom (pub Jan 2009)
2003-32 Vehicle strikes utility worker in short-duration work zone (pub Nov 2004)
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