Abstract: At approximately 7:00 p.m. on March 27, 2008, Employee #1 was located on the facilities loading dock, operating a depalletizing machine, which transports pallets of empty soft drink bottle cases (shells) into the facility with the use of power rollers. The pallets of shells are then lifted to a second level using an elevator that consists of forks moving between rollers. The bottles are then removed one layer at a time by a pneumatic carriage. The machine is completely automated and has a series of five lower and four upper electric eyes that control the rollers, elevator and pneumatic carriage. Operation of the machine is conducted primarily from the upper level where the controls are located; however, frequent trips to the floor level are necessary to remove shells that fall near the elevator of the machine. This is done using a metal rod or hook, measuring about 6 feet in length, to push/pull the shells out of the area. While Employee #1 was operating the machine, some shells fell near the conveyor portion of the elevator. As she entered the machine to remove the shells, the elevator descended. Employee #1 was crushed and killed by the elevator. Employee #1 was later discovered by the facilities maintenance mechanic, who reported that she was lying face down beneath the elevator. During the incident investigation it was noted that the elevator area of the machine was protected on two sides by metal frames that contained screens; however, the screen had been removed on the exit side of the machine. Therefore, it was determined that Employee #1 entered the elevator area through the exit side of the machine while it was in operation, which was not a common practice. No accident-related citations were issued.