Abstract: At approximately 11:30 a.m. on October 2, 1997, Employee #1 was kneeling down using a concrete saw to cut stone lintels. His foreman was approximately 60 ft away, talking with the foreman for another contractor. A coworker parked a Lull rough terrain forklift, model 6K-37, in front of the building where Employee #1 was working and about 4 to 6 ft south of where his work station was set up on the ground. The two foremen finished their conversation, and Employee #1's foreman started walking south toward the forklift. At 11:32 a.m., the foreman got on the forklift and started it up. He was then called by another worker; after answering the worker's question, the foreman checked the mirror for obstructions and began to back the forklift up. He had backed about 4 to 6 ft when he heard coworkers screaming for him to stop. The right rear tire of the forklift had run over Employee #1's legs and torso, crushing him. He was transported to the Maryland Shock Trauma Center, where he was pronounced dead on arrival. Subsequent investigation found several factors contributing to the accident, including (1) a lack of training in the safe operating procedures set forth in the forklift operator's safety manual; (2) the improper and unprotected layout of Employee #1's work station; and (3) the distracting actions of a coworker. Although the foreman had operated this type of forklift for 25 years, his employer had not provided him or the other operator with operator safety training, choosing to rely upon previous experience instead. The operator's safety manual, which was kept with the forklift, had not been reviewed with employees. Rule #1 on two warning labels on the forklift is "Do not operate this machine until you have read and are thoroughly familiar with the operator's manual." One of the rules in the manual states that, before starting the forklift, the operator must announce his or her intention to workers in the area and walk completely around the forklift to make sure the area is clear of personnel or objects that could be struck.