Abstract: At approximately 8:30 a.m. on June 21, 1999, Employee #1, the crew supervisor, relayed instructions about the days' work assignment to his coworkers. The coworkers began stacking blocks and pallets in the northwest section of the facility. Employee #1 went to prepare the small concrete mixer for the day's production. This entails ensuring the mixer is clean and clear of obstructions, then lubricating the inside of the mixer with diesel fuel. Employee #1 directed one of his coworkers to assist him. There was debris left in the mixer from the previous days work and Employee #1 decided to clean it out. At this point Employee #1 should have initiated the lockout procedure required by the employer. That procedure required that the power source be locked out by installing a padlock on the electrical control box with the handle in the off position. Employee #1 did not lockout the mixer and had climbed into the mixer and was scraping the debris into a chute at the bottom of the mixer. The chute leads to a conveyor which transports wet concrete to the blocking molds. Employee #1 asked the coworker assisting him to turn on the switch allowing the conveyor to carry away the debris he had gathered. The coworker was new and had not received any training on this equipment. The power control switches for the conveyor and the mixer were side by side and were not clearly labeled to indicate which button controlled which piece of equipment. The coworker pushed the wrong button and the mixer blades began to turn causing serious abdominal wounds to Employee #1. Employee #1 was killed.