Abstract: At approximately 1:40 a.m. on August 13, 1995, Employee #1, of Texpac Hide & Skin Ltd., was cleaning in the 10 1/2 ft heavy duty flesher area. Employee #1 was the operator of the flesher on the evening shift from 3:30 p.m. to midnight. He and a coworker were to clean the floor in this area following the shift. Another coworker, a member of the cleanup crew which worked from 10:30 p.m. to 2:00 or 3:00 a.m., was cleaning the flesher machine itself. Employee #1 was reaching into a gap of approximately 12 in. between a stationary drive shaft and an articulating drive shaft when the cleanup crew member, who was unaware of Employee #1's position, contacted a foot pedal, which caused the flesher to close. On closing, the articulated shaft rotated up and under the stationary shaft, catching and compressing Employee #1's head and killing him. The flesher was equipped with an electrically interlocked, 4-pedal, safety opening and closing system, which was designed to require near simultaneous (within 1 sec) contact of foot pedals by two operators at separate operating stations to initiate closing. Failure of a time delay relay in the safety system permitted employees performing cleanup to circumvent the system by jamming a wrench under one of the foot pedals. The flesher could then be closed by one employee activating the other foot pedals.