Abstract: At approximately 5:30 a.m. on December 5, 1998, Employee #1 and a coworker were working inside a mash mixer at a brewery. The foreman was observing both employees form outside this confined space. A chain-fall was attached to the section of the bottom head of the mash mixer that was going to be removed. When the coworker made the final cut on the first section of the bottom mash mixer head, the tension on the chain-fall caused this piece to move suddenly and unexpectedly out of place. Employee #1 lost his balance and fell approximately 12 ft through the newly created opening. Employee #1 was not utilizing approved fall protection at the time of the accident. Employee #1 was transported to the hospital and was admitted. Employee #1 dislocated both shoulders, suffered a broken right occipital bone, a broken left wrist, and had a blood clot removed from his brain.