Investigation Reports

Various workplace injury types illustrated, including a person falling, person drowning, person being electrocuted.

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

  • Type of industry involved 

  • The victim's age, sex, occupation 

  • The task(s) the victim was performing 

  • The tools or equipment the victim was using 

  • The energy exchange resulting in fatal injury 

  • The working environment 

  • Number of employees in the company 

  • Company safety program 

  • 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

Agricultural Silos Building Exterior Storage and drying of grains wheat corn soy sunflower against the blue sky with rice fields


Man worker uses a power drill to attach a cap metal roofing job with screws.


Mature Man Falling On Wet Floor In Front Of Caution Sign


Seascape of Hyannis on Cape Cod in Massachusetts

Fishing, crabbing and boating

Arborist climbing up the tree and cutting branches off with small petrol chainsaw

Logging and forestry

Inspection of each layer of laterite soil landfilling near vibratory roller compactor machine.


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)

big ten wheels truck with container for logistic running on the road under the sunset, background natural river, 3d and illustrator


Happy young saleswoman in modern supermarket.

Young workers

Young farmers examing planted young soy in spring

Hispanic workers

Regional fire-fighting exercise in the training area with urban and contract firefighters.

Fires and explosions

Cargo compartment of a cargo plane, commercial aviation, cargo transportation.

Permit-required confined space

red street cones sign stands on asphalt road during car accident outside

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