Abstract: At 5:45 p.m. on November 25, 2019, an employee was working for a plumbing, heating, and air conditioning contractor. He was a concrete and terrazzo finisher. He was cleaning the paddles of a concrete mixer by pouring water into it from a 5-gallon (18.9-liter) bucket. The mixer was attached to a Kubota Model SVL 95-2S track loader, with serial number 427072J01820. The mixer was used regularly or almost every day, and all employees cleaned it. The employee's left foot was resting on the mixer's discharge port gate. The gate's opening was 6 in. wide, 6 in. long, and about 3 in. deep (150 mm wide, 150 mm long, and about 75 mm deep). As the employee was dumping the last bucket of water into the mixer, his foot slid into the port. His foot became caught in the mixer paddles, and all five toes of his left foot were amputated. He was hospitalized. During an inspection, it was learned that employees were taught by both the firm's owner and the firm's lead trainer to clean the mixer with the exhaust gate open. Doing so allowed dirty water to drain from the mixer as clean water was poured in, despite the hazards associated with cleaning the mixer while the port is open. The firm's owner, in an interview, said that he had been cleaning the mixer that way since he acquired it and that he never told the employees not to put any part of their bodies in the open gate port while the mixer was running.