Abstract: At approximately 3:00 p.m. on July 10, 1994, Employee #2, of Besco Elevator Service and Repair, was lifting a 2,000 lb piston with a base-mounted winch without an effective signal or limit switch. The load hit the pulley block and the winch continued pulling, resulting in the winch being pulled off the concrete floor. The load fell back, lifting the winch and its rigging, entangling Employee #2 and pulling him up. He fell back and was taken to Good Samaritan Hospital, where he was treated for leg injuries and released. Employee #1 went through the first-floor elevator doorway and fell into the elevator pit. He was hit by a broken winch part and was killed. Violations found and cited include: general, T8CCR 4985(a); serious, T8CCR 3212(a)(2), 3328(h), 4970, and 5001(a).