Abstract: At 7:15 a.m. on September 10, 2012, an employee was working alone to change the manufacturing sizing parameters of a shell core molding machine intended for production that day. While leaning/reaching into the machine, the shell core machine closed on his head and arms. He suffered crushing injuries that resulted in his death. The incident investigation identified that the machine was in manual run mode; however, it was suspected that the equipment was placed in this mode from automatic mode when others worked to free the employee from the machine. However, the investigation was unable to determine why the employee was reaching into the machine.