A 33-year-old blender-operator (victim) suffered a crushing injury when he entered part of the blending machine he was operating. The victim worked at a poly-vinyl-chloride (PVC) pipe manufacturing facility. His responsibility was to blend additives to the PVC product for certain types of pipe products. While operating the blending machine he noticed a problem with one of the thermocouples that monitor batch temperatures. He and another co-worker decided to replace the thermocouple with a new one. While the co-worker was working on replacing the thermocouple, the victim proceeded to another part of the blender unit, possibly to check another thermocouple. While the victim was partially inside this part of the blender, the unit activated. The victim was caught by the machinery and pulled into the unit. The victim helped extricate himself from the machinery. He was transported to a local hospital and life-flighted to trauma center where he received treatment, but he died the same night. The MO FACE Investigator concluded that, in order to prevent similar occurrences, ALL employers should incorporate the following recommendations into their safety and health plans: 1. ensure that written lock-out/tag-out procedures are developed, implemented and enforced to protect workers from hazardous energy; 2. develop, implement, and enforce a comprehensive safety program which includes, but is not limited to, training of employees in hazard recognition and avoidance, and safe work policies including task-specific procedures; 3. routinely inspect and test safety lock-out devices and switches on machinery. These devices should not be relied upon to replace a properly initiated lockout/tagout procedure.