Abstract: At 9:45 a.m. on May 27, 2014, an employee was watching two members of his maintenance crew make a repair to correct the timing on an encoder gear box on a Bakery Equipment/Winkler (BEW) loader. Once the repair was completed, the loader was restarted to verify that the timing was adjusted properly. At that time, the guards that were removed prior to the repair were still off the loader. The employee wanted to check the oil level of the encoder gear box. At the time of the incident the back and north guards of the BEW loader had yet to be replaced from the repair of the gear box timing that had just been completed. Before the guards for the loader where reinstalled, the employee, in order to obtain a better view, placed his head into the opening, where the guard would normally be placed, and exposed himself to a moving part (gear arm) of the loader that intermittently rotated every 17 seconds. While the employee's head was in position over the top of the gear box, the gear arm rotated and pinched his head against the frame of the machine and caused a fatal injury. According to the Postmortem Examination Report from the Office of the Medical Examiner, the employee died from blunt force trauma of the head as a consequence of being struck by a gear arm.