Abstract: At 9:30 a.m. on December 11, 2018, an employee was working as a laborer for a firm that manufactured concrete pipe. He had worked for the firm for about 11.5 years. The firm employed about 900 people, with some 13 employees working at a pipe plant. The incident occurred in a pit at the plant. The employee was using a 4 pound (1.8 kg) sledgehammer to clean concrete residue from around a broken bolt in a Turmac core base in preparation of replacing the bolt. His supervisor had instructed him to prepare the area around the bolt while the supervisor went to get a replacement bolt. The core base was at knee height. Although the supervisor considered that it would be safer working on the bolt with it at waist height, raising the equipment would have required undoing the lockout/tagout of the system. Thus the supervisor decided to leave the Turmac core base at the level it was at when the bolt was found. The employee had a choice of tools for removing the concrete residue, including the sledgehammer, a pneumatic needling gun, and a pneumatic chisel. The employee used an overstrike with the sledgehammer. The sledgehammer glanced off the concrete material on the core base and struck the employee's left shin. He suffered a fracture to his lower left leg. He was transported to a hospital. He was hospitalized for more than 24 hours. The incident occurred after the employer had launched an initiative to remove all unnecessary sledgehammers from its manufacturing facilities to reduce the injury rate. The employer had issued a directive that there was no need to use a sledgehammer in the pit, and that the use of a sledgehammer there required the plant manager's approval. The plant manager had conducted a survey to identify and remove unnecessary sledgehammers from the plant. The manager had not approved the use of a sledgehammer in the pit. The supervisor was aware of the survey and directive but chose not to turn in the pit sledgehammer, thinking it should stay for some tasks.