Buffalo Run Golf Course and subsequent accident investigation report by Commerce City Police

On July 13, 2010 at approximately 1140 hours, I (Ofc.C.Dickey) responded to the Buffalo Run Golf Course, 15800 E 112th Ave on a report of an industrial accident that had occurred earlier in the morning. This is in the City of Commerce City, County of Adams, State of Colorado. It was requested that I respond to the location to investigate an industrial accident that had occurred at approximately 0500 hours the same morning.

According to the Dispatch call, Kirk Reiber, Golf Course Superintendent, had called in stating one of his employees had been run over by a tractor. The details of the call were that the male victim was conscious and breathing and sitting up, but had multiple injuries and was bleeding from several locations. Northglenn Ambulance arrived and transported the male victim to Denver Health Medical Center for treatment. I arrived and met with another supervisor, Tracy Schmer, who told me that Kirk Reiber was down at the hospital with the victim, James (Jim) Bohling. Tracy Schmer gave me the following information: At approximately 0500 hours, his crew was getting ready for the day's work. Jim Bohling was out in the east parking lot of the maintenance area, and was starting his tractor to let it idle and warm up. Tracy Schmer said another employee of his, Ron Pietras, ran back into the office where he and Kirk Reiber were talking, and told them Jim Bohling was hurt and yelling for help. All three men returned to Jim Bohling°s location in the parking lot, where they found him laying on the ground, bleeding. Tracy Schmer said he did not get too close, as he did not do well with the sight of blood. Tracy Schmer said he heard Jim Bohling telling Kirk Reiber that he had started the tractor, and that it had run him over and dragged him. He said they called for an ambulance, and Jim Bohling was transported to the hospital. Tracy Schmer showed me the tractor in the parking lot, which had run into a grey Dodge Durango. The tractor, a John Deere model 1070, had a red Lastec mowing attachment on it. He said they determined that after the tractor ran over Jim Bohling, it curved to the left and back around, into the back of the Durango, parked in the lot. The Durango was pushed into another vehicle, a silver Ford Thunderbird. At the time of my investigation, the tractor was still parked where it had stopped, and the Durango had not been moved. The Thunderbird had been moved forward a couple of feet by the owner, whom I later contacted. I began my investigation, sketching the scene and taking photos. I later diagrammed the scene, using the cell tower at the south end of the parking lot as a reference point. I spoke with the initial witness, Ron Pietras, who said he did not see the actual accident, but came out just after it happened. He said he was walking around the corner to check on his own tractor at the gas pumps, when he heard someone yelling for help. Ron Pietras said he went over to the source of the yelling and found Jim Bohling laying on the ground. Ron Pietras ran back inside to get help, returning with Tracy Schmer and Kirk Reiber. Ron Pietras later completed a witness statement for me. Kirk Reiber arrived a short time later, and I was able to talk with him about the incident. He gave me the same details that Tracy Schmer had, including what Jim Bohling had told him about the tractor running him over after he started it. I asked Kirk Reiber to show me how the tractor worked. He said the tractor involved had several safety features built in. One of these was that the tractor could not be started if it was in gear. The second was an emergency brake that should be set. The third is a pressure switch underneath the seat that will act as an engine kill switch if not depressed. Kirk Reiber said the operator would have to be sitting in the seat to engage the switch, and if the operator got up or off the seat, the engine power would be cut. He moved the seat forward to show me the switch. Next to the switch was a set of blue wires. Kirk Reiber told me it appeared as though this tractor had the safety kill switch disengaged (See photo 1808) and that the wiring should be connected to be operable. I asked Kirk Reiber if it was standard practice to disengage the wiring for this device and he said it was not. He said all the tractors and power units with that feature were checked several months ago for compliance, but that he was not aware this unit had been disconnected. I asked him if the maintenance workers knew how to disable this safety feature, and he said he did not think they did. Kirk Reiber said the neutral gear feature would have to be disconnected as well for the engine to be started while in gear. Ultimately, it was determined that Jim Bohling was on the right side of the tractor, between the tires, as it was parked facing north. He started the tractor while it was in gear, the brake was not set, and the tractor immediately rolled forward, pulled by the engine. It ran over Jim Bohling with the big rear tire, knocking him to the ground. The mowing attachment caught Jim Bohling, dragging him between it and the tractor, approximately 90 feet down the sloped driveway, where the attachment ran over him and the tractor then curved back around to the south. I looked over the tractor and the Lastec mowing attachment, finding very little evidence points to document. On one of the small wheels on the front of the attachment, I found a small spot of what appeared to be blood, and another on a rear wheel. I photographed the mower attachment from all angles and underneath. Kirk Reiber was able to Use the hydraulics to lift up the side "wings" of the mower so I could look under them. I also photographed the Durango and the Thunderbird, and obtained the registration and owner information for both vehicles. When the Durango was hit by the tractor, the force pushed the Durango forward about four feet, and it struck the Thunderbird that was parked ahead of it. The owner of the Thunderbird, James Adams, had pulled his car forward after the accident. I had him back it into place so I could take photos. I completed my scene investigation and obtained witness statements from Kirk Reiber and Ron Pietras. I then went down to Denver Health Medical Center to see what the status of Jim Bohling was. Jim Bohling was in SICU at the time I contacted him, and was being prepped for a CT scan. He had visible injuries to both arms, an abrasion on his head, bruising on his left shoulder, and his right leg had been casted. He was semi-conscious, but unable to speak due to the intubation. I spoke with Jim Bohling's wife, Deanna Bohling, and his daughter, Jill Nielsen, both of whom were at the hospital. I apprised them of the situation, and Deanna Bohling said her husband was very careful around tractors. She said he had worked around them all his life, having worked a farm for many years, and she did not know him to be unsafe. Deanna Bohling signed a consent for Release of Medical Records form, and I left the SBI form for the attending physician, Dr.Johnson, to sign and fax back to me. A late check on the John Deere model 1070 specs on the website showed the tractor alone weighed
approximately 3000 pounds. http://www.tractordata.eom/farm-tractor3/000/l/5/154-john-deere-1070.html On July 14, 2010, I (Ofc.C.Dickey) was advised that James Bohling had died from his injuries sustained in the incident with the tractor on July 13th. He was pronounced deceased at Denver Health Medical Center on July 14th at 0639 hours, by Dr. Colleen Foster. Cause of death was listed by Dr. Foster as "Traumatic Crush Injury". I returned to the Buffalo Run Golf Course to conduct further investigation. I met with Kirk Reiber, the supervisor I spoke with on July 13th. I asked Kirk Reiber numerous questions regarding the duties of James Bohling, operation of equipment, safety features on the equipment, and procedures for the maintenance workers. Kirk Reiber informed me that all of his employees receive the same safety training when they are hired, consisting of safety videos and one-on-one OTJ training specific to their areas of assignment. James Bohling was assigned to mowing "the rough", or the longer grass area of the golf course. He was assigned the tractor he was using the day of the accident, and Kirk Reiber said James Bohling was the only one to use that tractor and mower on a regular basis. Occasionally, another worker may use it, or may move it around to get to other equipment in the yard, but for the most part, it was operated by James Bohling. Kirk Reiber said James Bohling was a seasonal employee, meaning he worked from April to September, and was off during the winter months. He had worked at the Buffalo Run Golf Course for the last four seasons, and was at a different course in the Thornton area for the four seasons prior to that, doing the same mowing duties. James Bohling was a retired farmer, and had worked around tractors and farm equipment most of his life. Kirk Reiber said when the accident happened, he was inside the office talking with the other supervisor, Tracy Schmer. He said Ron Pietras ran into the office yelling that "Jim is bleeding" and needed help. Kirk Reiber said he grabbed his cell phone to call 911, and told several of the employees to get clean rags to Stop the bleeding. When he went out to where James Bohling was, Kirk Reiber asked what happened, and was told by James Bohling "The whole damn thing ran over me". James Bohling said he was standing beside the tractor and reached in to start it, and when it fired up, it was in gear and started rolling forward, rolling over the top of him and dragging him down the driveway. I asked Kirk Reiber about the condition of the equipment, with safety devices possibly disconnected. He told me that last year, they employed a mechanic named Danny Gonzalez, who worked for the course. He said Danny Gonzalez did not perform his duties satisfactorily, and that he was terminated in July of 2009. He said they (supervisors) were aware of numerous safety issues with the equipment, and that Danny Gonzalez had not repaired the equipment or replaced worn parts, especially the safety shutoff switches. He said when the switches would wear out, Danny Gonzalez would rewire or bypass the switches to save time and expense from having to replace them. Kirk Reiber said they hired a new mechanic in January of this year, named Brian Kayser. He said Brian Kayser had come in and personally inspected the entire fleet, making repairs, adjustments, and replacement of worn or broken parts, to include the safety shutoff switches. Bryan Kayser brought the fleet of vehicles and equipment up to proper standards, and personally took pride in keeping the fleet operating smoothly. He did not know why the safety seat switch or neutral switch on this particular tractor would still be disengaged or bypassed. Kirk Reiber showed me James Bohling's training binder. It contained a sign-off sheet of different categories related to training and safety, for the 2010 season. None of the categories had been initialed or dated. I asked Kirk Reiber about this and he said the returning employees generally did not go through the safety courses again unless they requested it or were having safety violations/issues. He also said they would not require the returning employees to be re-trained on duties they did from season to season. I concluded my interview with Kirk Reiber on this date. I had a phone number for Brian Kayser and left him a voicemail message to contact me. I also looked at a second John Deere tractor parked in the lot, near James Bohling's tractor. It was a different model, but I could see a similar safety switch under the operator seat that had also been disconnected, and the wiring was hanging free. I photographed this tractor and the switch wiring. On July 15, 2010, I made contact with Bryan Kayser at the golf course. I met with him privately, and recorded the interview with his permission. Bryan Kayser was visibly upset, and he told me several times that this incident was really hard on him. He said he felt responsible for what had transpired, since it was his machinery and equipment that had caused the death of James Bohling. Bryan Kayser was hired in January of this year. He said he had been doing mechanical work for golf courses for the last 20 years. Bryan Kayser said when he came to Buffalo Run in January, the fleet of machines and vehicles was in desperate need of repair and maintenance. The vehicles had safety mechanisms that were not working correctly, mowers that did not cut as they were supposed to, and machines that needed to be tuned up. He Spent several days going through the fleet, exhausting a large portion of his budget to bring the vehicles and equipment up to proper operating standards, to include the safety seat mechanisms on several units. I asked about James Bohling's tractor and mower. He said James Bohling was assigned that tractor, and that it was the only one he used, as his sole job on the course was to mow "the rough". Bryan Kayser said he inspected the tractor and the mower, and had to make repairs to the PTO (Power Take-Off) unit on the back, which powers the mower. He also performed general seasonal maintenance on the tractor, including oil and fluid changes, etc. Bryan Kayser said he never looked under the operator seat for the safety switch, as he had no need to. He knew the tractor started properly when he was in the seat, and it operated as it should when he was done with his work on it. Bryan Kayser Said he never thought to check on the seat or the neutral switch, as it did not appear to be an issue. Bryan Kayser said James Bohling never had mechanical issues with the tractor or the mower during this season, and that the only repair he had made this year would be to put a sharp blade on the mower or replace a faulty headlamp. Bryan Kayser said the general procedure at the end of the work day was for the operators to pull the tractors up to get fuel and the units rinsed off, as the grass buildup can cause rust. The unit is then parked in the area at the south end of the maintenance garage parking lot, until use the next day. James Bohling worked Tuesday through Thursday, so I asked Bryan Kayser if anyone had used the tractor on Friday or Monday, or over the weekend. He said he did not know of anyone that used the tractor during that time. On Monday, Bryan Kayser remembered seeing the tractor parked out by the fill-dirt stalls on the east side, but said that was not uncommon, as equipment is frequently moved around to get to other equipment that may be parked behind, or to make room as necessary. He said the tractor and mower sat in that position overnight on Monday, and was still there when James Bohling came to work on Tuesday. All of the keys are locked in a lock-box in the office until work the next day. I asked Bryan Kayser if he had seen any of the operators, to include James Bohling, starting their equipment while standing on the ground. He said he had, and that they were all guilty of it at one time or another, due to complacency. He said the tractors are designed to not be started unless they are in neutral, and the safety seat switch was engaged. I asked how this would be possible, and he said they would have to be bypassed. I asked how it would be possible to start the tractor while it was in gear, and he again said the neutral switch that completes the circuit would have to be bypassed. Bryan Kayser explained that the seat switch and the neutral switch complete a circuit with the engine and the starter, and that if one of those components was not in place, the engine would cut off or not start at all. If additional wiring was installed to complete that circuit and bypass the safety mechanisms, then the tractor could be operated without a person in the driver seat, and without the tractor being in neutral to get it started. It would also prevent the engine from being shut down during operation (in gear) when the operator got off the seat. I concluded my interview with Bryan Kayser, who was very cooperative with me the entire time. When we walked out to where James Bohling°s tractor was parked, I asked him to show me the neutral shutoff switch. He looked, but was unable to find an external switch for me to see. I have no further information on this case at this time. A detailed CAD diagram has been completed, and all applicable paperwork and witness statements have been included.