Abstract: On March 23, 1994, Employee #1 was using a vibratory compactor to compress dirt after completing underground pipe work. Employee #1 was observed by a coworker using the compressor in a back and forth motion to pack dirt in a 1-foot deep trench. Later, the coworker left the work area to get a drink of water and happened to turn around to see the compactor lying on its side with Employee #1 partially outside the cab. It was determined by the location of the equipment that Employee #1 had misjudged the means of exit from the 1-foot deep trench, causing the compactor to tip over. Consequently, Employee #1 fell and struck his head on a concrete sewer drain. He died from his injuries.