Abstract: On March 11, 2004, Employee #1, working in the lard department of a pork processing plant, was transporting a 5-gallon bucket of caustic soda from the third floor chemical storage area to the first floor to clean the meat processing equipment. The freight elevator had been locked and tagged out for repair earlier that day and the elevator car was locked out in the basement. The employee attempted to use the freight elevator and when he opened the doors on the third floor, he fell down the elevator shaft with the bucket of caustic soda. He suffered second and third degree burns on his head and upper body, a punctured lung, and several fractured ribs. He was transported to L.A. County General Hospital where he was hospitalized for treatment. The investigation revealed that the lockout of the freight elevator had not been communicated to the sanitation crew on the night shift.