Abstract: EMPLOYEE #1 WAS CLEANING A BLENDER USED TO MIX DRY POWDERS WITH OIL TO BE USED IN A PLASTICS EXTRUSION PROCESS. ANOTHER EMPLOYEE IN THE ROOM WAS CLEANING THE EXTRUDER. NOISE LEVELS IN THE ROOM WERE LIMITED TO THE SOUNDS OF COMPRESSED AIR BEING RELEASED. EMPLOYEE #1 WAS OBSERVED CLEANING THE BLENDER AT ABOUT 5:45 PM BY THE ASSISTANT FOREMAN. NO OTHER EMPLOYEE HAD A CLEAR VIEW OF EMPLOYEE #1. NO ONE HEARD ANY SOUNDS OF DISTRESS FROM HIM. HE WAS DISCOVERED, DEAD, IN THE BLENDER AT ABOUT 6 PM. THERE WAS NO LOCK-OUT PROGRAM IN EFFECT AT THE WORKPLACE. THERE WERE SOME SAFETY FEATURES IN THE BLENDER SYSTEM WHICH DID NOT FUNCTION PROPERLY. A MICRO SWITCH WHICH WAS DESIGNED TO DETECT THE ABSENCE OF COVERS ON THE BLENDER FAILED TO WORK WHEN TESTED. THE START/STOP SWITCH WAS EQUIPPED WITH A STOP BUTTON HOLD-DOWN. THE BLENDER COULD STILL BE OPERATED IN A "JOG" MODE WITH THE STOP BUTTON DEPRESSED. THE BLENDER FUNCTION SWITCH, WHICH WOULD HAVE PREVENTED THE BLENDER FROM TURNING WHEN IT WAS IN THE NEUTRAL POSITON, WAS FOUND IN THE REVERSE SETTING. IT APPEARS THAT WHILE BENT OVER INTO THE BLENDER, EMPLOYEE #1 ACCIDENTLY ACTIVATED IT, CRUSHING HIS SKULL.