Abstract: At approximately 2:15 p.m. on September 26, 2007, the second shift foundry supervisor discovered Employee #1, the operator of Number 1283 Jet Wheel Shot Blaster, trapped and unresponsive under the loading door of this machine. The door was 52-in. wide and 39-in. high, and was made of steel. The Jet Wheel Shot Blaster (Serial Number JW 80086) was used to clean castings after the shake out process, and was made by Jet Wheelblast Equipment in 1986. Under normal operating conditions castings leaving the shake out process are carried up to the Jet Wheel Shot Blaster via a powered hopper. Once reaching the Jet Wheel Shot Blaster the parts are dumped through the loading door opening into a barrel where the shot blasting process starts. The loading and shot blasting processes are automated, and the operator's role is to monitor the operating cycle. When found, Employee #1's head, left arm, and upper chest were trapped under the door. Employee #1 had been working alone in this area to clear castings that had jammed in the door mechanism. A pneumatic cylinder used to open and close the door was energized, and once the obstruction was removed the door came down on Employee #1. The foundry supervisor and other managers said that a written procedure was not in place for clearing jammed castings from the loading door, and that lockout is not required for this task. They added that employees are instructed to use a hand tool to remove the parts instead of their hands. Employee #1 had not been using this tool when he was injured. Employee #1 was pronounced brain dead on September 28, 2007, and died one day later after life support systems were removed.