Abstract: At approximately 9:10 a.m. on January 16, 1991, Employee #1 was assigned to oil and grease the 24 in. diameter rollers and plow arms of a large sand muller machine. This maintenance was done from outside the machine and, apparently, Employee #1 did not see the need to turn off or disengage the machine. At approximately 9:30 a.m., Employee #1, who was standing on the top landing of a stairway, instructed the machine operator to run the sand muller. The operator went to the control panel, losing sight of Employee #1. He was performing the normal, approximately 45 second start-up procedure when he heard a scream from inside the machine and pushed the STOP button. Employee #1 had been pinned against the wall of the sand muller by the plow arm. He suffered massive trauma injuries and was killed.