Abstract: Employee #1, an elevator mechanic, was working on the switches in an elevator that were malfunctioning in various ways. The in-the-car and top-of-car operating devices were not working correctly. The UP button worked on top of the car and the DOWN button worked in the car, but not vice versa. In addition, the switch that engaged the top-of-car device did not lock out all the in-the-car switches, as it should have. Employee #1 defeated the deadman key switch in the elevator by using a piece of wood to keep positive pressure on it. As shown on the surveillance video displays, Employee #1 was lying on the floor halfway in and halfway out of the elevator when it moved down, crushing him between the fourth floor landing and the elevator ceiling. He was killed. It is believed that Employee #1 had unintentionally pressed the DOWN button in the elevator, which should have been locked out had the switch on top of the car been functioning correctly. He was working alone at the time of the accident.