Abstract: At approximately 2:00 p.m. on April 1, 1996, employees were preparing low fin steel tubes for shipping in a stacked-rack wooden box. The 4-ft-long tubes were bundled in groups of 100, and each bundle weighed 3,400 lb. The tubes were tied together by hand using a 0.5-in. black plastic (polypropylene) strap and a wire buckle. The tubes were stored three bundles to a tier, in stacks of four tiers. Each tier was separated by 4 by 4 or 2 by 4 lumber. Employee #1 was standing in a 3-ft-wide aisle, placing a 40-ft spreader bar on top of the rack of tubes in preparation for hoisting. When the 1,200-lb-spreader bar was set atop the bundled tubes, one of the bottom bundles apparently shifted, breaking or stretching its plastic strapping. This allowed the tubes to slide off the rack toward the aisle in which Employee #1 was standing. Employee #1 was trapped upright, pinned by tubes from his feet to his chest. The spreader bar, which was still attached to the crane and on top of the tubes, also came down and struck Employee #1 in the chest. He was killed.