Abstract: At approximately 1:00 am on November 23, 2009, Employee #1, an apartment building property manager, attempted to perform a hydraulic repair of the elevator located in one of the employer's apartment buildings. He entered the elevator shaft to adjust the hydraulic piston packing flange bolts, but did not follow lockout/tagout procedures. He tried to stop the flow of hydraulic fluid by placing his hand over the leak. The elevator car dropped to the bottom of the elevator shaft, and he was trapped in the refuge space under the elevator car for four hours before he could be extricated. He sustained serious injuries to his right hand and was transported to Cedars-Sinai Medical Center, where he underwent surgery. He was hospitalized for three days.