Abstract: On August 12, 1988, Employee #1 and a coworker were kneeling in front of a 1,000 lb tank that had been raised 2 ft off the ground by a forklift. They were attempting to change a discharge pipe located on the side of the tank near the bottom when the tank suddenly slipped off the forks and onto Employee #1. He was crushed to death. The cause of the accident is unknown but the tank was most likely not centered and stabilized on the forks. The tank pipe was being changed with a wrench and the employee may have exerted enough force to move the tank. Lift truck malfunction is not a cause. The company had a policy according to which employees were to secure tanks to the forklift mast with chains before transporting or elevating them. The policy was not adhered to and all employees were found to be untrained in it.