Abstract: Employee #1, a technician/loom operator, was in the second night of training another employee to operate a loom, which was normally a one-person operation. Employee #1 decided that the trainee was fairly competent in operating a loom so Employee #1 began to complete other tasks nearby, while keeping an eye on the trainee's production. The loom was weaving a heavy fabric, a felt, which was approximately 20 feet wide. The point of operation included two horizontal metal bars approximately 21 feet long, which repeatedly moved back and forth, toward and away from one another, while a shuttle device carrying a strand of thread traveled back and forth across the leading edge of the felt. There were three sets of controls for the loom. Lighting was good. The noise was loud and both men wore hearing protection. Several times before the accident, the shuttle had incorrectly lodged itself in its firing box, causing the loom to automatically shut down. The operator repositioned the shuttle and started the loom. When the loom stopped again, the trainee thought that the shuttle was the problem again. He checked the shuttle, found it to be correctly positioned, and then restarted the loom with the control at his side. As the shuttle started its cycle, he looked down the length of the loom and saw Employee #1 slumped over, with his head in the point of operation. Employee #1 then fell backward, with blood flowing from his head. The trainee immediately stopped the loom, but not before Employee #1's head was crushed, resulting in instant death. Emergency medical care was called and arrived within minutes, but there was nothing that they could do. Apparently Employee #1 had stopped the loom by activating the control at the end of the loom away from the trainee. He then proceeded to inspect the underside of the fabric by sticking his head down between the two metal bars. No eye contact or other form of communication was established between the two workers. When the loom started again, the point of operation closed on Employee #1's head. Factors contributing to the accident were the lack of an adequate lockout/tagout system, multiple duplicate controls, and the failure to establish communication between the two workers.