Abstract: At approximately 2:30 p.m. on October 31, 1995, Employee #1 and a coworker were loading a 43,000 lb steel coil onto the mandrel of slitting equipment. Lateral straps holding the coil together were removed once it was loaded onto the transfer cart or coil buggy, which moves in two directions on tracks, toward and away from the mandrel. Once the straps were removed, the steel in the middle of the coil sagged into the hollow opening. Employee #1 grabbed a short stick that was in the area and pushed the sagging material, or steel tail, back up and out of the way so that the coil could slide onto the stationary mandrel shaft. As the tail was being held, another coworker operated the coil buggy from controls located on the opposite side where he could not observe the coworker with the stick. As the buggy was moving in toward the mandrel, Employee #1 was crushed between the coil and the adjacent slitter machinery. He suffered severe internal injuries and died approximately one week later.