Abstract: Employee #1 was an employee of a dyehouse, where garments and piece goods are dyed. He was in the process of repairing Ellis Dye Machine #18. The Ellis Dye Machine (a washwheel) consists of a dye drum with three doors on one side through which materials are fed. The operation is similar to that of a household washer, but the drums are hydraulically raised during loading and unloading operations because of the machine's size. Employee #1 suffered fatal head and body fractures when he positioned himself underneath the machine and a loss of hydraulic pressure occurred, causing the drum to lower and crush him to death. The causal factors were the absence of a blockout/tagout procedure and the inoperability of the disconnect on the control panel.