Abstract: At approximately 3:23 p.m. on March 22, 1990, Employee #1 was operating the setting machine at the #3 brick machine in plant #6. He was cleaning out pieces of clay from between the spreader bars. The brick machine operator noted that his column slugs were being rejected at the setting machine. He checked at the setting machine and observed Employee #1 cleaning between the spreader bars on the table. He also noted that the setting head/carriage was carrying brick to the kiln car. He returned to his position where he observed the head/carriage return to the home position then immediately go down, and come up a few seconds later without a brick. He sensed that something was wrong. He ran to the setting machine and found Employee #1's upper body lying on the table. Employee #1 died. The operator yelled "man down" and the operator of the #2 brick machine ran and hit the emergency stop button. The setting machine was being operated in the automatic mode. Employee #1 had bypassed setting the machine to the manual mode and tried to fool the machine by hanging weights on the spring-loaded switches so that the machine components would do the opposite of what they were programmed to do. Immediately after the accident, the panel was checked and a weight was found on the table close switch. This allowed the table to remain open so that Employee #1 could remove the clay caught in the spreader bars of the table. While Employee #1 was performing this procedure, the head/carriage returned to home position; the signal was already there for the head to come down and pick up a load of brick. When the table opens, the limit switch is signaled for the head to come down. The head came down, catching Employee #1's head between the fingers on the head and the spreader bars of the table. Causal factors include improper use of machine controls (not operating machine according to manufacturer's design) and lack of machine guards or guarding devices.