Abstract: At approximately 9:15 a.m. on December 13, 1995, an employee stopped a Besser block machine to unjam some cinder block pallets. The employee, an unskilled operator, completed the job at approximately 9:30 a.m. and proceeded to air blow the work area where concrete had fallen. Looking around, he asked a coworker, a senior maintenance mechanic who was standing nearby, where Employee #1 was, as he was helping to clean up the concrete. Both workers thought that Employee #1 had gone to get a hoe, so the operator turned the switch to the ON position. He then heard a loud groan from in back of the machine, turned the switch to the OFF position, and ran around to find Employee #1 caught under the machine. Employee #1 received fatal head and neck injuries. No lockout or tagout was utilized, nor did either employee look around to ensure that all other workers were safely positioned.