Abstract: Employee #1, a laborer for seven years at Rosehills Cemetery, Whittier, CA, usually worked alone to dig, fill, and maintain grave site properties. On November 1, 1996, he elevated a dirt-tilt wagon and dumped some dirt. He then lowered the trailer but recent rains had caused mud to build up around the tail gate, preventing it from closing all the way. Employee #1 activated the hydraulic lever to re-elevate the tilt trailer. He walked behind the trailer, reached over the tail gate with his shovel, and began breaking the mud loose while the trailer was still elevating. Just as the trailer reached its apex, the tail gate suddenly swung open and pinned his left foot to the ground. His foot was crushed and the first, second, third, and fourth toes were fractured. On December 20, 1996, the DOSH-West Covina office completed its accident investigation. The employer was cited for the following violations: Citation 1, items 1-13 regulatory/general violations; and Citation 2, serious, for failure of the supervisor to recognize the safety hazards associated with operation of the dirt-tilt wagon, and failure to train employees in its safe use. The employer did modify the hydraulic tilt lever so that now as soon as the lever is released, the elevating or lowering stops. This is not enough however, because even when it is fully raised, a worker attempting to free a stuck tail gate could receive a similar injury.