A field evaluation of the case of a robot related fatality in a manufacturing facility worker was conducted, and the results of the evaluation were used in the formulation of safety recommendations pertaining to ergonomic design, training, and supervision for work with robots. This fatality occurred in a small automotive support industry employing 66 die cast operators. In July, 1984, a 34 year old die cast operator with 15 years experience went into cardiopulmonary arrest after being pinned between the right rear end of a rotating hydraulic robot and a safety pole; the worker died 5 days later. Literature on robot related fatalities was reviewed. This accident has several characteristics in common with four reported fatal accidents in Japan: victims were experienced and trained in robotic operations and safety; all entered the work envelopes of the robots in order to personally rectify perceived problems; all violated existing safety measures; all were struck from behind by the robot; the robots pushed or crushed the workers against another piece of equipment. The following procedures were recommended: operators should never be in the work envelope while the robot is functioning automatically; programmers should operate the robot at a slow safe speed and be aware of all possible pinch points; refresher courses should be provided for experienced programmers, operators, and maintenance workers. The authors conclude that research and dissemination of information on psychological factors, safeguarding, education and training, and surveillance of near miss accidents are needed to better understand the factors and to ascertain their effectiveness in preventing future robot related injuries and fatalities.