Abstract: At approximately 12:05 a.m. on April 14, 2006, Employee #1 and a coworker were cleaning out the inside of a feed mixer at a facility that manufactures forage enhancement and animal nutritional products consisting of dairy and beef feed. The mixer was used to mix various ingredients such as oats, soybean meal, molasses, and vitamins, in the manufacturing of their products. The mixing equipment consisted of an upper auger section, where the ingredients were mixed, and a lower section, called a surge tank, where mixed ingredients were dropped through a pneumatically operated mixer discharge gate. The gate separated the upper and lower sections of the mixer. The ingredients were then transferred out of the tank via a conveyor that was located at the bottom of the tank. To clean the mixer, a series of safety steps were required for securing the area for work. First, the electric power for the auger and conveyor would be disconnected and locked out. Then the pneumatic supply for the gate would be opened by an employee going into the plant control room and holding open a toggle switch with a rubber band. The next step was to close the air valve and disconnect the air line for the mixer, which was located on the mixer. Although the first two steps were followed, the third step was not performed. Employee #1 and his coworker had been working in the mixer for about 4 hours; Employee #1 was located in the lower portion of the mixer, while the coworker was in the upper section. As Employee #1 was reaching up through the gate opening to assist the coworker with cleaning off the auger, the rubber band slipped off the toggle switch. The switch returned to its closed position, pinning Employee #1 between the gate and edge of the gate opening. Emergency services were called, and the local fire department responded to the accident. Employee #1 was pulled from the tank and but he died from his injuries. The accident investigation revealed that there was no confined space attendant on site, and no other employees were in the facility. The employer had no written lockout/tagout procedures for the mixer or any other equipment in the facility. In addition, Employee #1 and the coworker were not wearing any retrieval gear.