Abstract: A standard size station wagon was driven onto a 4 post, floor-mounted, automotive hoist and raised approximately 5 ft 6 in. to change the oil. The company president raised the auto to the full upper limit and engaged the safety lock. Employee #1 then went under the vehicle and was about to remove the drain plug from the engine base when the hoist failed and allowed the vehicle to fall, crushing Employee #1 between the vehicle and the floor. He died. The two main bolts that secure the hoist platform to the hoist cylinder were not inserted when the hoist was installed approximately 16 months before the accident. This hoist had been continuously operated until the time of the accident with the hoist platform resting on the cylinder collar. Without the bolts to secure it, the platform frame finally slipped off the cylinder collar, allowing the hoist to fail.