On September 24, 1996, 53-year-old male elevator construction foreman (the victim) was killed and his helper, an elevator constructor (employed by another subcontractor) was injured, when the hydraulic elevator car they were working under fell on them. The two were adjusting the hydraulic cylinder when the car fell, trapping them in the elevator pit. Two wooden poles (4x4 by approximately twelve-feet long ) used to keep the elevator from falling were placed leaning against the guide rails. The car was approximately fifteen inches above the poles, which they did not tie in place. The poles were knocked out of position when the car fell due to the sudden loss of hydraulic pressure and trapped the two workers under the car. The elevator apparently did not fall evenly to the bottom of the pit. This permitted the rescue team to enter the pit area and extract the injured. However, rescuers had to use air bags to help raise the car to remove the victim. The MD/FACE Field Investigator concluded that to prevent similar future occurrences, employers should: 1. Train employees in the recognition of hazards, and methods to control hazards. 2. Develop, set up and enforce comprehensive written instructions for making adjustments to hydraulic elevators. Develop, set up and enforce comprehensive written instructions for making adjustments to hydraulic elevators.