Abstract: At approximately 4:30 p.m. on August 16, 2006, Employee #1, an engineer, was performing machine adjustments on the drills of a P251 LH Fender Inner Drill Fixture made by Bel-Kur, Incorporated. The employee was working inside the factory alone, and had crawled through a 25.5-in. by 22.5-in. hole in the barrier guard, into the confinement of the machining process. He had not locked out the machine before entering. The machine accidentally started up and the employee was crushed in a secondary automated drilling operation. Employee #1 was found by coworkers and pronounced dead by the local coroner on site. It was determined that contributing factors to the accident were: that the employee was not protected by any additional sensing devices that would have prevented the accidental start-up of machinery within the barrier guarding, and that the machine had not been locked out. The employee had worked for the company approximately thirty years and was trained in lockout tagout.