Abstract: Employee #1 had been working for three weeks at a cement mixing factory that mixed and bagged dry concrete and grout products. He was operating the cement mixer, a large vat into which components in bags were emptied and then mixed by paddles, The paddles were attached to a central shaft and operated by a powerful electric motor. The mixer vat was covered with thin steel plates which were not welded or bolted to the mixer vat but may have appeared to be mechanically connected. Employee #1 had loaded the mixer vat and turned on the paddles. The owner and a coworker were in other areas of the facility and did not see the accident; however, Employee #1 apparently stepped up from the platform onto the top ledge of the vat either to clean up or to remove empty component bags that he had inadvertently thrown there. The cover moved and Employee #1 fell into the mixer and was pulled down into the mix. One of the paddles caught Employee #1 and pinned him to the wall of the mixer. Employee #1 died. Employee #1 and another temporary employee were the only employees of the company owner, who had been in business for 6 months