Abstract: On the morning of January 3, 1991, Employee #1 and coworkers, of Anco Metal Improvement in Gardena, CA, were attaching a 1/2 in. by 6 in. by 10 ft long aluminum plate section to a hoist. The section had P-holes to which straps could be bolted to hang the section onto the hoist. Bolts had been attached to the left end and to the middle, and Employee #1 was lifting the section for the third bolt to be inserted when the middle bolt broke, causing the section to drop on his feet. According to the safety coordinator, the workers had used a 5/16 in., undersized bolt instead of the 1/2 in. bolt that was necessary. According to the leadsman of the group, the bolt was 1/2 in. but it had been used previously. Employee #1 said that bolts are not supposed to be used again because the bolts and sections go through an anodizing process and are immersed in acids and other chemicals that corrode and weaken them. Employee #1 examined the bolt after the section dropped on him and felt certain that it had already been used. When asked for the broken bolt, the safety coordinator said it had been thrown away.