Abstract: On April 22, 1994, Employee #1, a hoist operator at the Atlanta Detention Center construction site, had been on the job approximately 8 days. He was attempting to lubricate the counterweight guide rollers of the #2 personnel/material hoist and was positioned where the #1 hoist counterweight lowers to the ground. This activity was not coordinated with the operator of the #1 hoist and no lockout procedures were used. The #1 hoist was elevated to the top level by the hoist #1 operator, which caused the counterweight to lower all the way to the ground, crushing Employee #1. He was taken immediately to Grady Hospital, where he died shortly thereafter.