Abstract: Employee #1, a mold mechanic for a medical syringe manufacturer, was retrofitting injection-molding machines with fireproofing blankets. The plant had over 20 injection molding machines, and the work was split between several maintenance workers. The employer had no standard procedure for installing the blankets. Employee #1 would partially move the guard away from the area as he wrapped the blanket around the heating rings of the injection arm. By 3:00 am, Employee #1 had completed all of his assigned machines and started on machines that had not been assigned to him. He began working on one 480-volt, 30-ampere machine without locking it out. The employee was found dead. It was concluded that he had been electrocuted. A postaccident inspection of the machine conducted by the company's electricians and an outside electrician determined that one of the three relays controlling the heating ring zones on the injection arm had a contact that remained closed. This contact allowed the circuit controlling the heat rings to remain energized while the employee was working. The manner in which Employee #1 had been installing the blankets exposed him to ready contact with energized terminals. The coroner's autopsy did not address the possibility of electrocution because the circumstances behind the death were not relayed to him until after the autopsy had been completed. The coroner did not examine the possibility of electrocution or look for any evidence of electrocution on the body.