Abstract: At approximately 7:00 a.m. on October 4, 1988, Employee #1 was sitting across the empty pallet inverter of an Aberson brick press, with his feet hanging down in the empty pallet transporter. He was receiving 55 by 1 by 16 1/2 inch trays from a coworker who was standing adjacent to the operation, and then replacing trays or pallets in open spaces on the empty pallet hoist. The process of shutting down the line and replacing pallets that had jumped out during the course of a shift is called palletizing. The two employees had set the control switch for the pallet inverter and transporter to manual at the system control panel, believing that this was an effective lockout method. However, approximately 75 feet away at the end of the conveyor line, where fresh bricks are off-loaded and sent into kilns, another coworker thought it was time to start his shift and hit the control switch to start the conveyor. Almost instantly, Employee #1 sensed the transporter moving and yelled for someone to shut the machine off. At the same time he tried to climb out, but the cycle had been set in motion. Even though the main controls were hit within seconds, he was caught by the empty pallet transporter chain cross-connecting rod, lifted up, and slammed into the empty pallet hoist. He was knocked unconscious and sustained a fractured right leg above the ankle and two fractured ribs. Employee #1 was cut from the machine and transported to Prince William Hospital, where he was admitted for treatment.