Abstract: On July 6, 2006, Employee #1 was working as an equipment operator (CEO II) with the California Department of Transportation, or Caltrans. He had been working for Caltrans at various locations for twenty-six years. On the day of the accident, he was part of a crew resurfacing the Caltrans West Bay paint yard in San Francisco. The crew consisted of Employee #1 and at least two coworkers. The first coworker was operating a Model CB-434D Caterpillar Vibratory Asphalt Compactor, or roller, with Serial Number CAT CB434ACNH00422. The roller had been purchased by Caltrans a year earlier and had been used a few times at different jobsites. The hydrostatic propel control system, which provides the service brake, had been the subject of a manufacturer's recall the previous year. At approximately 9:30 a.m., the compactor's operator had just completed a patch job and was getting off the patch. He was driving into a concrete driveway, up toward Employee #1 and a second coworker, who were standing on the concrete driveway and against a low loading dock. They motioned to the operator that he had cleared the patch and should go into reverse. The roller's length was 13 feet, 9 inches, and concrete driveway's width to the loading dock's berm was 18 feet, 10 inches, leaving about 5 feet for the roller to stop without hitting Employee #1 and his coworker. The operator tried to stop the roller and go into the reverse mode, by putting the propel control into neutral. The roller kept moving forward, though, hitting Employee #1 around his lower left thigh and knee, and pinning him against the low dock. The operator tried to put the propel control into reverse, but the roller jerked back at Employee #1. Then the roller backed up approximately a foot and came back at Employee #1 with force, hitting him around his right knee. It finally backed up. Employee #1 was laid down on the ground. The San Francisco Fire Department emergency medical services paramedics arrived at the scene and transferred Employee #1 to the San Francisco General Hospital. Employee #1 sustained an open fracture of his left femur, closed fractures of his right femur, kneecap, and tibia, and a fracture in his lower back. He was hospitalized for over a week, and he underwent two orthopedic surgeries. The investigation of the accident revealed that Caltrans was not familiar with a special feature of this roller, namely, the hydrostatic propel system, which provides slow stopping to ensure smooth paving. The vehicle stopping distance is between 5 and 15 feet, depending on the speed of the vehicle, which is significantly more than the stopping distance of the Ingersoll-Rand roller that the employees usually operate. Furthermore, another operator had reported difficulties with the handling of the Caterpillar roller, which had resulted in a similar accident on or about January 2006. Caltrans was cited one Serious Accident-Related violation. T8 CCR 1509(a) requires employers to identify unsafe conditions and work practices whenever new substances, processes, procedures, or equipment are introduced to the workplace that represent a new occupational safety and health hazard (1509(a), Ref: 3203(a)(4)(B)); and to provide training and instruction whenever the employer is made aware of a new or previously unrecognized hazard (1509(a), Ref:3203(a)(7)(D) and (E)). Other violations of Title 8 were observed, and the employer was cited accordingly.