Abstract: Employee #1 was in a welding shop working on an H-bolster, a large metal frame that was part of a truck assembly for a locomotive. The 100 in. wide by 92 in. long by and approximately 8 in. thick bolster weighed 2,800 lb and had steel plates on each corner. In its center, there was a 32 to 33 in. section, concave on one side and convex on the other. A coworker helped Employee #1 use a 6-ton hoist and one set of double hook chains to set the bolster on two of the steel plates. The coworker needed the hoist for his job, so Employee #1 secured the bolster in an upright position by spot-tacking one end of a 21 1/4 in. long by 4 in. wide by 1/2 in. thick steel plate onto the back of the bolster and the other end onto a work table. According to the coworker, Employee #1 used a method called "blind tacking," meaning that he did not use a welding hood but held one hand in front of his eyes as he worked. Another 8 1/4 in. long by 1 1/4-in. square metal bar was attached to the bolster and the table in the same manner. The coworker told Employee #1 three times that he needed to chain the bolster to the table and not get under it, and every time Employee #1 replied that he'd done this before and it would be fine. Employee #1 then sat on a stool and began welding on the concave section of the bolster. Another coworker who entered the shop and saw Employee #1 said he was shocked to see that the bolster was not supported by a chain. Soon afterward, a second coworker punched in, retrieved his tools, and then stepped around the side of the welding curtain to see what Employee #1 was doing. Employee #1 stopped burning and waved at the second coworker. He was starting to get off his stool when the bolster fell, crushing his head. Employee #1 was killed.