Abstract: Employee #1 had just finished welding detail work onto a large 6,000 lb I-beam, 28 ft long by 37 in. high. The beam was lying across two 31 in. high horses. Using an overhead hoist with a chain sling, Employee #1 rolled the beam up onto its 12 in. flange so that the welds could be inspected. He then uncoupled the chain and let the hook fall to the floor on the far side of the beam. Company procedure was to manually clear the hook before moving the hoist. Instead, Employee #1 raised the hoist with the chain and hook dangling on the far side of the beam. The hook caught the bottom of the flange and rolled the beam back onto the him, pinning him and crushing his chest. He died almost instantly.