Abstract: On July 16, 1990, Employee #1, a maintenance man with a technical education, was automating and revamping a barrel loader located above a conveyor at the work site. The so-called "lockout" consisted of only a toggle-type switch on a nearby wall. Employee #1 was trying to adjust the machine's timing. Thinking he had shut the machine off, he crawled between the piston-driven loader and a conveyor brace and tried to bend the wire on the micro switch. This activated the steel loader, which moved downward and crushed Employee #1's upper body against the brace. He died a few hours later on July 17, 1990. Employee #1 had not bled off the air to the pneumatic piston. The weather was clear. The inside of the building was hot and the employee had worked more than 12 hours.