Abstract: On April 8, 2007, Employee #1, an oil well driller, was working with his coworkers, when the drill bit that they were using became plugged. The driller raised the drill string and let it fall 20 feet and stopped it abruptly in an attempt to unplug the bit. This did not work and caused the brake to "break over". Some of the coworkers attempted to fix the brake by attaching the winch line to the brake handle and pulling it back. This did not work and it bent the shaft on the brake. They then tried to remove the drum guard. Five of the coworkers suggested that they should try to take the guard apart into three pieces so it would be easier to handle. As they started to remove the bolts, the tool pusher informed them that all five of them could remove the guard in one piece. The guard was removed in one piece and they attempted to "break over" the brake by using 36-in. pipe wrenches to pull the pivot point back over. However, this did not work. They, then, attached the wrenches to the pivot point directly under the driller's console, and pulled the wrenches with the winch line. This did get the brake to "break over". Instead of using the five coworkers to put the guard back in place over the drum, or taking the guard apart so it could be more easily managed, three coworkers were directed to put the guard back in place while the tool pusher and the motor man worked on the bent brake handle. Employee # 1 was standing on top of the drum with his back against the drill line. The derrick man and a floor hand were trying to roll the guard up to Employee #1 when the brake handle slipped and hit the throttle, causing the drum to rotate, pulling Employee #1 into the drum. The drum rotated two full revolutions before the coworkers could stop it. Employee #1 was cut into two pieces and pronounced dead at the worksite.