A 24-year old male machine operator (the victim) died after a coil cart he was repairing fell on top of him. The victim was working with another worker on a machine designed to press coils of steel into flat sheets, when the coil cart used to bring steel coils to the press failed to operate. The victim discovered that the chain had come off the chain-and -sprocket assembly under the cart. He used a forklift to lift the coil cart approximately 1 foot from the floor, and with the coil cart suspended on the forks, crawled under the coil cart to re-install the chain. The coil cart slipped off the forks of the forklift and crushed the victim. A co-worker, who had been holding a flashlight for the victim, saw the coil cart fall and tried to pull the victim out from under the cart but was unable to move him. The cart fell directly on the victim's upper body. Workers in the area called an ambulance and the shift leader. They used an overhead crane to lift the coil cart from the victim. County emergency medical services and city police responded and assessed the victim. Paramedics determined that the injuries had been immediately fatal and pronounced the victim died at the scene. NIOSH investigators concluded that, to prevent similar occurrences, employers should: Ensure that control of hazardous energy (lockout/tagout) procedures are reviewed, revised where applicable, implemented, and enforced. Ensure that machines/equipment are used for the purpose they were intended for. Ensure that good housekeeping is practiced throughout the facility on a regular basis. Ensure that a competent person is available on all shifts to identify and correct hazardous situations.