Abstract: EMPLOYEE #1 WAS THE SAFETY DIRECTOR AND QUALITY CONTROL TECHNICIAN FOR A CEMENT PROCESSING PLANT. THE PROBLEM WHICH LED TO THE ACCIDENT WAS THE FAILURE OF SAND TO FLOW THROUGH 3 VERTICAL GATES, WHICH EMPTY SAND BY GRAVITY FLOW ONTO A CONVEYOR BELT, FROM WHERE THE SAND IS TRANSPORTED TO THE MIXING PROCESSOR. THE SAND WAS APPARENTLY NOT FLOWING THROUGH THE GATES BECAUSE IT WAS WET. BECAUSE OF DAMPNESS,THE SAND APPARENTLY HAD COMPACTED ABOVE THE GATES, CAUSING A VOID, OR 'CAVERN', BETWEEN THE SAND PILE AND THE CHUTES LEADING TO THE GATES. EMPLOYEE #2 (THE GENERAL MANAGER) AND OTHER EMPLOYEES WERE IN THE TUNNEL WHERE THE SAND GOES THROUGH THE CHUTES AND THE GATES AND ONTO THE CONVEYOR BELT. THERE WERE THREE GATES/CHUTES INVOLVED, AND SAND WAS NOT FLOWING THROUGH ANY OF THEM. RAPPING ON THE CHUTES CAUSED A HOLLOW SOUND, WHICH IN TURN INDICATED THAT THE VOID WAS ABOVE THE CHUTES. AT SOME POINT DURING THE ATTEMPT TO DISLODGE THE SAND, GATE #1, WHICH WAS THE NORTHERNMOST OF THE GATES, BEGAN TO FLOW FREELY FOR A MOMENT AND THEN STOPPED AGAIN. AT THIS POINT, AN EMPLOYEE IN THE TUNNEL WITH EMPLOYEE #2 INDICATED THAT SOMEONE HAD APPARENTLY PUT A BOOT INTO THE CHUTE. EMPLOYEE #2 THEN INVESTIGATED AND FOUND A SECOND BOOT. HE REACHED ABOVE THE BOOT AND, UPON FEELING A HUMAN LEG, ATTEMPTED TO FIND A PULSE ON THE FEMORAL ARTERY, DIRECTLY BEHIND THE KNEE. FAILING TO FIND A PULSE, HE SUMMONED ALL THE HELP HE COULD FIND IN THE PLANT YARD. THE ENTIRE YARD CREW (8 TO 11 EMPLOYEES) ATTEMPTED TO EXTRICATE THE BODY BY HAND AND WITH SHOVELS. AT THIS POINT NO ONE KNEW WHO THE TRAPPED PERSON WAS. PRIOR TO THE ACCIDENT, EMPLOYEE #1 HAD BEEN SEEN BY SEVERAL EMPLOYEES IN THE PLANT YARD. EMPLOYEE #2 HAD SPOKEN TO EMPLOYEE #1 APPROXIMATELY 15 TO 20 MINUTES PRIOR TO THE ACCIDENT, WHEN EMPLOYEE #1 HAD ASKED IF HE COULD HELP WITH THE PROBLEM. EMPLOYEE #2 INDICATED THAT HE KNEW OF NOTHING EMPLOYEE #1 COULD DO TO HELP. EMPLOYEE #2 STATED THAT, BECAUSE OF EMPLOYEE #1'S DUTIES, HE HAD COMPLETE ACCESS AT ANY TIME TO ANY PART OF THE FACILITY. NONE OF THE INTERVIEWED EMPLOYEES HAD SEEN HIM ON OR NEAR THE SAND PILE. NOR COULD THEY REASONABLY SPECULATE AS TO WHY HE WAS THERE. MOST OF THE EFFORT TO DISLODGE THE SAND WAS IN THE TUNNEL BELOW THE SAND PILE. THERE WAS NO REASON FOR ANYONE TO BE ATOP THE SAND PILE. THE APPARENT REASON FOR THE ACCIDENT WAS EMPLOYEE NEGLIGENCE IN PUTTING HIMSELF IN A HAZARDOUS POSITION ATOP THE SAND PILE. THIS ERROR IN JUDGEMENT LED TO HIS DEATH.