Abstract: At approximately 4:30 p.m. on July 27, 2012, Employee #1, an electrician, was placing a 208 Volt AC single-phase electrical plug on a flexible cord. He was working with two coworkers (both control assembly engineers) on a pole core assembly machine (a machine built for an automated automotive product line). Employee #1 crouched underneath an elevator conveyor consisting of four rollers (powered by air, 90 psi) in the raised position in the rear of the machine and added a 208 Volt AC single phase plug to go on the robot controller located in the rear of the machine. There were two sets of conveyor rollers, one on the bottom and one on the top and the elevator conveyor covers four rollers which moves up and down to move trays in and out of the machine. The coworkers were at the front of the machine and working at a table with two laptops tied into the programmable logic controller to load program data for the machine parts to move. When the machine powered down for the downloading of a program, one of the coworkers released the air from the machine and when he did this the elevator conveyor moved downward and pinned Employee #1 between the two conveyors. Employee #1 suffered a broken spine and other fractures to his upper body and died a week later at a local hospital. The investigation determined the employer had not provided training to their employees on safe procedures when working with the equipment involved in the incident.