Abstract: Employee #1 and three coworkers, the morning maintenance crew, were assigned to change the hoist drum on a "stiff-leg" type overhead crane. The JSP was not reviewed with the employees prior to their starting the task. They tried to remove the bolts from the main hoist drum gearbox while the main hoist was still under load. An approximately 18-ton load was on the hoist, and when 16 of the 18 bolts had been removed, the gearbox separated enough to allow the pinion gear to disengage. The cable drum started to rapidly free-wheeling, and the load dropped to the floor. As the load reached the floor, the momentum of the free-wheeling drum started rewinding the cable backward. Employee #1 was either straddling or sitting on the hoist drum when the gears disengaged. Although there were no witnesses, it is believed that Employee #1 was knocked across the drum when the gearbox separated. He was either crushed by the sudden movement of the free-wheeling drum, or beaten by the cable as it backlashed. Employee #1 was killed.