Abstract: At approximately 2:00 p.m. on June 27, 1994, Employee #1 and five coworkers were starting up a composite line after repairing a break in a top coil that had caused the line to shut down. At start-up, a coworker noticed that the top drive-side adhesive alignment system was off by about 1 1/2 in. At least once a day, any one of the coworkers would adjust the system by going up to the drive-side upper adhesive platform and, using an Allen wrench kept on the platform, adjust two set screws. The platform, which was seven feet high and had several holes in the floor, was next to the core oven; the temperature there was approximately 120 degrees F. Employee #1 offered to make the adjustment and climbed to the platform. About five minutes later a coworker found him on the platform, suffering from a compressed skull fracture. Apparently Employee #1 fell while on the platform and may have broken the light beam on an unguarded reciprocating 605 psi hydraulic chasing eye assembly that was located on the north side of the platform. It is assumed that this assembly was activated and Employee #1 's head was caught between it and the I-beam; when his body fell out of the path of the light sensor, the assembly returned to its original position. Employee #1 was transported to the hospital where he died on July 6, 1994.