Abstract: At approximately 10:15 a.m. on November 26, 1993, Employee #1, a driver and 13-year employee of the Golden Gate Disposal Co., San Francisco, CA, was performing his regular duty of cleaning a side loader compaction vehicle after his shift. It is company policy that every driver, at least once a week, clean the garbage left behind the blade in the hopper or sump area. Employee #1 had been performing this task for approximately a year. Employee #1 stated that, as usual, with the truck's engine running, he stood on the packer cylinders (blade cylinder) to clean the garbage because it is easier and would not put a lot of pressure on his back. As Employee #1 stood on the blade cylinder, the blade retracted and crushed both of his legs below the kneecaps. Employee #1 believes that at the time of the accident, the machine was set on manual controls wherein the operation of the compactor platen is controlled by dual levers that are connected to the main control valve. With the selector switch turned to the manual position, one can use the control lever to move the platen to pack or retract. He stated that there is no reason for him to operate the machine in Auto mode and he has never used it, though another employee has stated that he uses Auto mode quite frequently. He added that, because there were no specific written procedures developed for this task, he assumed that his procedure was easier and faster than other methods. Neither Employee #1 nor the other driver of the side loader truck had been trained as to how the lever works or how to clean the hopper area behind the blade. The employer had assumed that the employees knew how to properly clean the vehicles. The employer did not supervise the employees to insure that such work was being done in a safe manner, nor did he make a thorough survey of the conditions of the site to determine, as far as practicable, the predictable hazard to employees and the kind and extent of safeguards necessary to implement the work in a safe manner. It is known that if the vehicle's engine had been off and the key removed from the ignition, that the unexpected movement of the compactor's plate (blade) would not have occurred. Serious violation citations were issued for violation of T8CCR4355(a)(2), T8CCR4355(c)(5), and T8CCR3314.