Abstract: On February 5, 1993, Employee #1, an elevator mechanic, was servicing a passenger elevator in a 23-story apartment building. The elevator's door interlock was broken at the first floor level, and it could only be repaired from inside the shaft. Because of the location of the repair, the mechanic had to work below the elevator car, which was positioned one story above the work area. The car's main disconnect was not locked out. The car traveled down and crushed the mechanic to death when he completed his repair of the door interlock. Besides the causal factors of the car's location and the failure to lock out the main disconnect, several other factors contributed to this fatality. First, if Employee #1 had pulled another form of power disconnect known as a pit switch located in the pit of the elevator shaft, the elevator car would not have been able to move. Second, the location of the pit switch, although not compliant with the latest elevator codes which require its placement within 48 inches of the doors, cannot be considered inconvenient because it was within 10 feet of where Employee #1 was crushed. Third, the exterior pull pin of the interlock, which allows the doors to be manually opened in an emergency, was also in disrepair. Because this pin was broken, it was not removed to access the area of repair. Had it been removed, the car would not have moved even when the secondary component was repaired by Employee #1. Its presence in the interlock system closed the circuit and allowed the car to travel down and crush him.