Abstract: On September 27, 2010, Employee #1, a maintenance mechanic with CP Kelco (a food additive manufacturer), was repairing a bucket elevator that was used to dump a powdered substance into a hopper at a level of 16 ft, 8 in. above a concrete floor. He was standing at the hopper level on a 4 in. horizontal beam clearing a jammed chain that held a bucket onto the elevator. To do accomplish this, Employee #1 was leaning over the elevator and striking the chain with a 10-lb sledgehammer. When he cleared the jam, the elevator dropped about 4 ft and then came to a sudden stop, with him riding it on his stomach. Employee #1's left lower leg struck the sharp metal edge of a bucket. He was hospitalized for a laceration. Employee#1 had been tied off with a 6 ft lanyard that was secured near his feet; however, the lanyard was of sufficiently length to activate in the short fall. Although the electrical controls had been locked out, slack in the cable holding the elevator was unrecognized and it was not blocked to prevent it from falling.