Abstract: At approximately 12:40 a.m. on May 25, 1996, Employee #1, of the U.S. Gypsum Company, climbed a barrier guard to access the adjusting nuts of a belt conveyor. He was using a wrench to work the adjusting nut while the 35-ft-long conveyor was in motion. While making the adjustment, Employee #1 lost his footing and was pulled into the discharge hopper. He suffered mechanical compression and died of asphyxia by suffocation. Employee #1 had not been instructed to perform any type of work on the equipment, and it was not a function of his job classification. He had been trained in lockout-tagout; but he had not implemented the lockout procedure before making the adjustment.