Abstract: On September 3, 2007, Employee #1 and four coworkers were installing a transformer on a power pole in an easement behind a residence in Beaumont, CA. The employer had been subcontracted by the power utility to replace transformers at various poles in southern California due to a recent heat wave. The crew first removed the faulty 25-kilovolt AC transformer without incident. Employee #1 and a coworker then attached an electric capstan to the pole at a height of approximately 4 ft. After rigging up the new Howard Industries 50-kilovolt AC transformer, serial #3716912607, Employee #1 began to lift it into place. One coworker was in the backyard of the residence, holding the tag line, which was wrapped around the midsection of the transformer. Two other coworkers were on the pole, ready to install the new transformer once it was in position. The foreman was standing in the easement, between 16 ft and 19 ft north of the pole. A rope attached to the top of the transformer ran up the pole, through a pulley transformer gin, with sheave, and back down to the capstan. The rope was wrapped around the drum of the capstan approximately four times. The free end was held by Employee #1, whose job it was to keep tension on the rope so that it would not unravel from the capstan drum. The transformer had reached a height between 8 ft and 9 ft when the rope began to bind up. Employee #1 took his foot off the pedal, which stopped the capstan from turning. He then took two steps forward, possibly in an attempt to provide the rope with slack to unbind it. The foreman later stated that as he saw Employee #1 step forward, the first wrap of rope around the capstan drum had enough slack to come away and fall off the end of the capstan drum. The line then began to unravel quickly and the transformer fell straight down on Employee #1, crushing him. He sustained multiple fractures and suffered cardiopulmonary arrest. Employee #1 was taken to San Gorgonio Memorial Hospital, where he was pronounced dead.