Abstract: Employee #1, a 50-year-old lead truck mechanic, had many years of experience and a reputation for insisting on safe procedures. The investigation disclosed that the night driver had placed a truck on the east side of the scales and filled out a report noting an air leak. The driver was aware of a clutch adjustment problem as well, but thought the day driver had filled out a report on that. At 4:50 a.m., Employee #1 clocked in. At approximately 5:45 a.m., he was found lying under the left front truck wheel in the truck shop. Employee #1's head had been crushed by the truck as it rolled back. He was killed. The maxi brake was not set, the truck was in gear, the keys were in the dash-mounted switch (ignition), the remote starter switch pedal was attached to the starter terminals, and the wheels were not chocked. The Oakdale, CA, Police Department report indicates that Employee #1 was in a stressed mental state and had a history of bizarre statements and responses.