Abstract: At approximately 1:00 a.m. on January 26, 2002, Employee #1 of CBI Services was part of a crew servicing an Alimak Elevator at a construction site located at the Tesoro Refinery in Anacortes, WA. Two coworkers were in the elevator car, while Employee #1 was on top of the car greasing the rollers located along the corners of the mast and at the bottom of the counterweight. Apparently the operator thought he heard a signal to run the elevator up. When he did this, Employee #1 was bent over between two guardrail posts that are around the top of the car and over the counterweight hitch. According to eyewitnesses, he appeared to be reaching out with his right arm to grease the bottom rollers of the counterweight. His head appears to have been in line with the bottom of the counterweight and one of the mast braces. When the elevator went up, it appears that the counterweight came down and crushed his head against a mast brace. The counterweight hitch (that is attached to the elevator car top) appears to have then pushed his upper torso against a tower support. The victim suffered traumatic crushing head wounds and fracture wounds to his upper left torso. He was transported to a hospital in Anacortes where he was pronounced dead. It appears that two coworkers, including the victim's foreman, were trained on a different type of elevator, and did not know that the operator's control box was portable and should have been on top of the elevator under the direct supervision of Employee #1. The red shut-off button on the top and other safety power interrupt features were not used.