Abstract: At approximately 8:00 p. m. on December 23, 2011, Employee #1, a 31-year-old male of Maplegrove Gluten Free Foods Inc., was dumping scrap pasta into a roll-off container on a steep ramp. He was at the end of his shift. He first drove the Crown sit down (Forklift Model Number 50FCTT-188 and Serial Number 1a154913) Industrial Truck out to the outside incline ramp with a collection bin to dump the scrap. The brakes failed. The Crown bounced backwards into an adjacent roll off and then into a concrete wall. Employee #1 then got the stand-up Hyster Industrial Vehicle (Model Number N45ER and Serial Number C138DO1821J) to dump scrap into the roll off. The brakes failed on the Hyster. The Hyster bounced into the adjacent roll-off and then into a concrete retaining wall where Employee #1's foot extended outside the line of the Hyster, and his foot and ankle were crushed. Employee #1 was hospitalized, and his foot was amputated from this event. There were no witnesses to this event. Other factors to this event were the failure to maintain the Industrial Trucks and Employee #1's foot extending outside the line of the Hyster. The employer's Injury and Illness Program was ineffective in three elements, (Element 2) a system for ensuring that employees comply with safe and healthy work practices, (Element 4) procedures for identifying and evaluating work place hazards and (element 6) methods and/or procedures for correcting unsafe or unhealthy conditions, work practices and work procedures in a timely manner based on the severity of the hazard. Gluten Free Foods Inc. was a commercial bakery primarily manufacturing pasta.