Abstract: Employee #1 was conducting pre-maintenance on a conveyor belt and motor. This consisted of oiling, greasing , and cleaning the dried cement from the conveyor belt and motor under the packer head carriage. From conversations and interviews with the employer and employees, Employee #1 was cleaning the conveyor belt and motor under the packer head carriage with the machine running. It was done this way because the carriage assembly had to be raised and lowered to oil, grease and clean. The company does not have a Lockout/tagout program. It was theorized that Employee #1 was cleaning the motor under the carriage assembly, using a wrench. The carriage assembly had to be low enough to reach the motor. During this cleaning process, Employee #1 dropped the wrench. Employee #1 climbed on the conveyor belt to find the wrench and was pinned between the packer head assembly and conveyor belt. At the time of the accident, the packer head carriage assembly controls were in neutral. When in neutral, the carriage assembly slowly lowers. Before he died, Employee #1 told the first person to arrive at the scene that he was trying to find a wrench that he had dropped. The wrench was later found in the conveyor belt after the machine was stared again.