Abstract: On November 20, 2011, Employee #1 opened an access door on the top of a fermentation tank to perform tank prewash activities utilizing a high-pressure water hose to presoak the sides and agitators inside of the tank. The tank was energized and the agitators were turning. The tank was approximately 18 ft deep and contained approximately 4 ft of finished liquid product the employer described as "13 percent beer". Sometime during the presoaking activity, Employee #1 fell into the tank for an unknown reason. There were no witnesses to his activities. Coworkers found Employee #1 unresponsive on the bottom of the tank. He was pronounced dead at the scene by a local physician.