Abstract: At approximately 7:30 p.m. on July 14, 2007, Employees #1 and a coworker, both ash cleanup laborers, were instructed to shovel fly ash into a conveyer inspection hatch. A chain driven conveyer was used to transport fly ash, which was a byproduct of solid waste incineration. The fly ash previously backed up out of the inspection hatch and onto the floor adjacent to the conveyer, due to a motor failure in hoppers Number 1 and Number 2, which were attached to the conveyer system. Employee #1 and the coworker were shoveling, while the conveyer was operating. The top of the conveyer at the site of the accident was approximately 29 in. off the ground. The conveyer was square and its depth was 21.5 in. The overall width of the conveyer was 59.5 in. The inspection hatch opening was 18 in. by 32.5 in. The conveyor was custom designed by the Ashtech Corporation of Ohio. Employee #1 and the coworker were shoveling fly ash into the inspection hatch opening, when the coworker walked approximately five ft to the adjacent outer wall of a stairwell and leaned his shovel against it, as he was contemplating wetting the fly ash down and using a wheel barrow or bobcat to haul it away. At that time, the coworker had his back turned to Employee #1, when he heard Employee #1's scream. The coworker turned around and found Employee #1 standing in the inspection hatch opening with his legs pinched between the inspection hatch edge and the moving conveyer flight. The coworker attempted to pull Employee #1 from the inspection hatch but with no success. Subsequently, the coworker ran to his shift supervisor for help, and the supervisor radioed the control room to shut the conveyer off at approximately 7:50 p.m. Employee #1 had both legs amputated at the knee level and trauma to the upper body. Emergency services were called, and Employee #1 was pronounced dead at the scene. The coworker believed Employee #1 was trying to cross the conveyer to shovel the fly ash on the other side. There was a lack of safety training, machine guarding, and lock out tag out procedures.