Abstract: At approximately 10:25 a.m. on May 7, 2004, Employee #1, a worker in a food warehouse, had just returned from a break when he observed that the combination Alvey palletizer and Lantech stretch wrapper was in fault mode with its alarm sounding. Having been an employee for four years, trained in the operation of this machine, Employee #1 was able to identify the problem: A pallet being displaced had a malformed top layer. In order to perform adjustments to the machine, Employee #1 entered the keyed access control area, which gave him access to the back side of the machine. As Employee #1 realigned the cases on the pallet and placed a slip sheet on top of the pallet of cases, he stepped on the rollers of the stretch wrapper. Following this adjustment, he stepped backwards in order to step to the platform below and got his right foot caught between the frames of the palletizer discharge conveyer and the Lantech Stretch wrapper frame. Employee #1 lost his balance and fell, breaking his leg. Emergency services were contacted and Employee #1 was transported to a local hospital, where he was hospitalized and treated for his injury. The accident investigation revealed that the accident was due to there being no safe platforms available for employees required to perform minor adjustments.