Abstract: On December 9, 1996, Employee #1, a crane belt oiler, was working from the side platform of a crane. Because the weather was cold, she decided to get out of the wind and clean the crane's inner components. She opened the outer sliding door, then the inner swinging guard doors, exposing the crane's drums and clutches. She was cleaning with a rag and a spray bottle of mineral spirits when she apparently slipped, and her hand became wedged between two revolving clutches. She sustained serious injuries, and her hand was amputated two weeks later after failed attempts to save it. Employee #1 continued inpatient and outpatient treatment involving skin grafts until January 31, 1997, when she suffered a massive pulmonary thromboembolism (blood clot) that resulted in her death. Employee #1 died at home on the same day that she had been schedulked to have more surgery. All of the crane's guards were in place at the time of the accident,. Employee #1 had received training, and she held a Class B card in the operating engineers' union.