Abstract: A mechanic was assigned to make repairs on all the employer's equipment. The mechanic and the employer had devised a procedure to repair tree spades. The procedure involved job-made attachments using bolts and a chain to secure the parts of the tree spade during replacement. It was designed to be a two-person operation, and the mechanic was always the one who was actually on the tree spade replacing the broken part. On April 16, 1993, while the mechanic was at the equipment yard, two coworkers called to tell him that a tree spade needed to have a part replaced and that they would be arriving shortly to help him in the replacement. The mechanic began the operation by himself. He did not secure one attachment with bolts, did not use a cotter pin to secure one pin, and did not attach the chain to secure the parts of the spade together. After raising a part to align it with one attachment, he stood in front of the blade and wiggled it to properly align the broken part with the attachment. The blade fell, crushing and killing him.