Abstract: At approximately 12:30 a.m. on April 14, 2011, Employee #1 was performing his duties as an industrial truck operator with Direct Chassis in South Gate, CA. His primary employer was Kelly Services, Inc. Direct Chassis, a private, limited-liability company, assembled tractor trailer goosenecks, the portions of the trailer that connected to the tractor truck. At the site, manual and pneumatic hand tools were used, and industrial trucks were operated. Employee #1 was using a Hyster Model Number 50 industrial truck (Serial Number F187V10568E) to separate two goosenecks that weighed approximately 1,500 pounds each and were held together by a nylon ratchet tie down. According to the general manager of Direct Chassis, some delivered goosenecks did not have the pneumatic hose connection harness, known as a "glad hand", and they were being separated from those that were equipped with them. Using the industrial truck, Employee #1 placed the forks between the upper and lower frame rails of the upper gooseneck and raised the two goosenecks off the ground. The lower gooseneck was completely supported by the nylon tie down. Employee #1 then crawled under the elevated goosenecks, and the lower gooseneck fell on him. Employee #1 was killed, and a coworker found him lying face down in a fetal position, with the lower gooseneck on top of him and the tie down loosened. Separating the goosenecks was a new procedure, and according to the shift manager, Employee #1 had only separated them one other time prior to the incident. Because there were no direct witnesses or video recordings of the incident, it was not possible to determine precisely why Employee #1 went under the goosenecks. It appeared, however, that he may have been attempting to loosen the ratchet tie down by opening the tie down buckle, which was located under the stack of goosenecks. Based on a visual inspection of the ratchet tie down buckle, it did not appear that the gooseneck fell due to a mechanical or structural failure of the buckle. Cal/OSHA determined that the accident was caused by Employee #1 going under the suspended load of the industrial truck and being crushed when the load fell. A general citation was issued to Direct Chassis, LLC, because the employer lacked knowledge that the hazard existed. Employee #1 had received forklift operator safety training. Based on interviews of other employees, it was a violation of Direct Chassis' safety rules to be underneath a suspended load. A dispatcher from the South Gate Police Department reported the industrial accident to Cal/OSHA on April 14, 2011.