Abstract: At approximately 11:43 a.m. on October 31, 2005, Employee #1 was operating a clutch mechanism on a mortar-mixing machine; a required step when the consistency of the mortar mixture is not sufficiently wet. When the mixture is lacking proper consistency, the paddle mixing unit within the mixer can jam, which requires the operator to collect the jammed mortar and actuate the clutch mechanism to reverse the direction of travel of the paddle wheel. This can sometimes cause the mixer to snap back. As Employee #1 activated the mixing machine's clutch mechanism, he was struck on the side of his head by the handle of the clutch mechanism that extended from the mixing unit. Employee #1 was hospitalized and treated for a severe concussion. The accident investigation revealed that although the employer had a safety program, hazards associated with the clutch mechanism were not included. Additionally, the handle of the clutch mechanism was bent, when it should be straight as designed. Also, the company had a safety latch located below the clutch handle that was to be inserted into a slot when cycling the clutch; however, Employee #1 failed to insert the latch.