Abstract: At about 11:36 p.m. on January 23, 2004, Employee #1 was operating a 3-ton, floor-operated, overhead Engineering Hoist Crane (Serial Number 34628). This crane was relocated to the company's Oakland facility in December of 2002. A Strato-Vacuum lifting device (Model Number 27300-4, Serial Number CR-3175) was purchased in 1996 and attached to the crane. Sometime later, this lifting device was modified to have three suction cups instead of four. Each cup was rated to lift 1,000 lbs. Employee #1 was using the device to lift a 4-ft by 12-ft by 1-in. aluminum plate that weighed about 710 lbs. There was another plate of the same size that was stacked under this plate. Both plates were stored on a temporary platform. The top plate was located 3 ft above the floor, when, for an unknown reason, Employee #1 pushed the button to deactivate the crane. This caused the vacuum device to release the plate, which fell and struck Employee #1's head, killing him. One contributing factor in the accident was failure to maintain and test the vacuum device. The suction cups had tears, a vacuum hose was severed, and a vacuum fitting was leaking. Another contributing cause was failure to proof-test the crane, both initially and after structural modifications. A third factor was the vacuum lifting device being wired with the crane power switch.