Abstract: At 8:15 a.m. on August 10, 2011, an employee was crouched in the throat of a Harris shear. He had changed out the blades on the shear cross head (downward moving member) and was about to change the blades on the fixed shear head base member. To accomplish this task the employee had to crouch down and reach into the 3 foot by 3 foot throat opening. An overhead material clamp, 6,000 lbs., was positioned via hydraulics with vertical members sliding down an open section in the base. The entire crew had initiated a group lock out tag out (LOTO), but in this instance a pin block to prevent movement of the clamp had not been implemented. The employee was seated cross-legged on the floor of the throat area, reaching back to pry the lining. The employee moved the lining and the clamp came down over his neck and body while he was in his bent position. The employee received a crushing injury to neck and back, and was pinned in that position, resulting in asphyxiation.