On March 9, 1998, a 24-year-old night-shift foreman (the victim) died of injuries when he fell approximately 13-15 feet from a piece of equipment known as a "hay de-stacker". The victim had been trying to clear a "jammed" hay bale on top of the de-stacker when he was pinned in the machine's sweep arm mechanism. After some effort, his fellow employees released him from the machine, but the hay bales that he had been standing on collapsed and he fell head first, landing on the steel decking of the bale staging platform. Emergency medical persons responded and transported the victim to an area hospital, where he later died from head injuries suffered in the fall. To prevent future similar occurrences, the Washington State Fatality Assessment & Control Evaluation (FACE) Investigative team concluded, that persons working with machinery, should follow these guidelines: 1. A Lockout/Tagout program should be instituted to protect employees from hazardous energy when working on machines, equipment or processes. 2. Anytime an individual has a need to work on a piece of machinery or equipment, then that piece of machinery or equipment must be shut down, turned off and locked out. 3. Employers should provide training and education related to the hazards of energized equipment, provide an understanding of the equipment safeguards and the basics of lockout/tagout. 4. Routine audits/inspections should be performed on the facility's "Energy Control Program/Lockout-Tagout Program". 5. When new, used or reconditioned equipment is introduced to the work place, a review of safety precautions should be conducted in conjunction with the equipment manufacturer. The review should include any and all regulatory compliance parameters that apply to the equipment and the operation of the equipment. 6. Safe access should be provided, such as ladders, platforms, etc. with appropriate fall prevention/fall protection measures, to allow operators to effectively deal with equipment/machine issues.