Abstract: The Starcase draw furnace, serial #TC42115-1, of Midland Ross in Toledo, OH, had been shut down for maintenance. When Employee #1 placed himself between the charge car and the door frame, intending to open the furnace door for additional cooling, he activated the wrong air solenoid valve and manually activated the charge car valve. The safety lockout pin did not hold the charge car, which moved forward, pinning Employee #1 against the door jamb. His chest, abdomen, and skull were crushed with a force of approximately 2,500 lb. A length of 1 1/4 in. schedule 40 steel pipe had been used as a machine guard safety lockout pin to prevent charge car movement. This was inadequate; the pipe bent and slipped out of its retaining brackets, allowing the charge car to move forward.