Abstract
A fatal accident occurred when a right angle gear box on an auger elevator disintegrated freeing the outboard end of a rotating PTO shaft. The tractor, acting as a stationary power source, flailed the PTO shaft which then struck and killed a farmer. No similar occurrences have been reported for the nearly 2000 similar units which have been used for over a decade. This paper studies a number of fundamental failure modes in order to determine which failure modes created the accident. Systematic analysis showed that the accident was caused by unusual misuse of the product. Known safety control concepts do not preclude this unforeseeable event.