Abstract: On July 10, 1993, Employee #1 and a coworker were following the normal daily routine in the elephant barn. After watering two elephants, they bathed and worked each elephant individually, all while the elephants were restrained by chains. Then Employee #1 unchained Tilly, the elephant, while the coworker stood close by as backup. When Tilly was unchained, Employee #1 told the elephant to "steady," which means to remain in one area and not move. When both employees went to unchain the other elephant, Tilly moved and took steps toward the center of the barn and in the direction of the two employees. Employee #1 approached Tilly, commanding "move over." Because Tilly did not move right away, Employee #1 again commanded "move over" and cued Tilly physically with an ankus. Although Employee #1 had not yet touched Tilly, the elephant hit her with her head and trunk, knocking the employee several feet away. Tilly then ran up to the employee and started kicking her in the head and chest area. The coworker used her ankus and verbal commands to bring the elephant back under control and away from Employee #1. Employee #1 was treated by paramedics at the scene and died at the hospital an hour later of collapsed lungs.