On January 2, 2002, a 37-year-old maintenance mechanic (the victim) died after being caught between the rear of a vacuum cooler tube and the cooler tube’s door. On December 31, 2001, the victim and his shop foreman changed the control valve that controlled the air flow that raised and lowered the vacuum cooler tube's 2,000-pound door. On the morning of January 2, 2002, the foreman instructed the victim to check to see if the door was operating properly before the vacuum cooler was placed back into service. Using the control on the pneumatic valve, the victim partially raised the door. As he positioned himself between the door and the rear of the cooler tube, one of the air lines on the pneumatic valve blew off, allowing the door to lower, pinning the victim between the door and the rear of the cooler tube. The foreman heard the rush of air and walked around the tube, finding the victim pinned. He held the air line on the pneumatic valve by hand, and raised the door allowing the victim to fall to the shop floor. Coworkers initiated cardiopulmonary resuscitation while the foreman called 911 from the shop office. The emergency medical service (EMS) responded and transported the victim to the hospital where he was pronounced dead. NIOSH investigators concluded that, to help prevent similar occurrences, employers should: 1) develop, implement, and enforce a comprehensive written safety program for all workers which includes training in hazard recognition and the avoidance of unsafe conditions; 2) continually stress the importance of following standard operating procedures: 3) Additionally, manufacturers should: evaluate system components to determine which would be the most reliable and provide workers with the safest work environment.