Abstract: On March 28, 2003, Employee #1 was a member of the sanitation (clean-up) crew. She and another employee hand cleaned some of the conveyors. Some of the conveyors had their belts removed, exposing the drive shafts and sprockets. After the hand cleaning, the two employees removed their lockout/tagout devices. They did not replace the belts on the conveyors or guard the exposed shafts and sprockets. The other employee re-started one of the conveyors and went to the conveyor so he could pressure wash it. A few minutes later, Employee #1 was caught in the exposed shaft and sprocket of another conveyor that had been re-started. It was not determined how this other conveyor was re-started. She was wearing a rain coat, and the rain coat apparently became caught in the drive shaft sprocket of the conveyor. As the coat wrapped around the shaft, her arm was pulled into the drive and her coat became entangled in the drive shaft. She was found dead entangled in the drive shaft.