Abstract: At approximately 3:40 p.m. on July 11, 1994, Employee #1 was instructed to open a metal sliding door as a coworker operating a dock mule tractor approached. When the coworker was approximately 12 ft away he applied the brakes, but be could not stop the vehicle's movement in time. The tractor struck Employee #1, pinning him against the metal door. He was transported to the Naval Hospital, where he was examined and then released. The next morning Employee #1 was still in pain and he was rushed to the hospital, where he was again checked and released. Employee #1 died on July 12, 1994, of a ruptured small intestine that resulted in a massive internal infection. The fatality was not reported to OSHA because management was waiting to determine if the death was due to an industrial accident.