Abstract: On March 4, 2011, an employee was directed by her manager to move some cases of beer. The cases were in a dry stock area, and she was told to move them down to a basement storage area using a material handling lift, or dumbwaiter. Use of the dumbwaiter was restricted by the owner to authorized personnel only, and this group did not include employees. The owner did not know the actual capacity of the hoist and made the assumption that the maximum capacity was 500 pounds. Accordingly, the owner advised his managers not to exceed 250 pounds. Since employees were not to use the dumbwaiter, they were not informed of this capacity limit restriction. It was not posted either. The opening to the lift on the first floor was at waist level, and the platform on the lift measured 68.5 inches by 46 inches. The employee loaded 25 to 30 cases of beer on the lift. The employee loaded the cases of beer by placing them on the ledge of the opening and pushing each case back onto the lift. Each case of beer weighed approximately 30 pounds. The total weight on the lift was at minimum 750 pounds, most likely exceeding the weight capacity of the hoist. There were no witnesses to what happened next, but there was a coworker who heard the employee crying for help. The coworker found the employee lying on her back on top of the material handling lift, with her head toward the opening for the lift. It is presumed that as the lift started to fall, it somehow caught the employee and pulled her down, flipping her over, and causing her to land on top of the lift. The employee was transported to a hospital, where she died from her injuries three days later.