Abstract: At approximately 5:00 a.m. on April 22, 2009, Employee #1 was preparing to load regrade oil into a rail car on the facility of ACH Food Industries, Inc., an edible oil and nondairy creamer manufacturer. The supervisor noticed on the control panel that the tank was full, instead of being empty, and paged Employee #1 twice in approximately 30 minutes. When Employee #1 did not return pages, he began searching for him. The supervisor climbed the ladder of the rail car and saw Employee #1 in the bottom of the car. He called to Employee #1 but got no response. He then went to the control room and phoned for emergency services. The supervisor lowered a 4-gas meter into the rail car and found the oxygen content to be approximately 14.6 percent. Emergency services arrived and extracted Employee #1 from the tank car. He was pronounced dead at the scene. The cause of death was due to cranial and cerebral injuries.