Charlie has worked in a bakery for seven years. The work is somewhat monotonous and Charlie seeks to enlighten the atmosphere by playing practical jokes. Charlie climbed into one of the mixing machines so that he could leap out and give a fellow employee, David, a surprise. Charlie has done this type of thing fairly frequently over the years. The foreman has often told him not to, but rather lightheartedly as he too seems to enjoy Charlie’s antics. David is not working on the particular morning when Charlie hides in the mixing machine. Eric, a worker transferred from the cake department, turns on the mixing machine and Charlie is killed.

All of the employees in Charlie’s department know of the rule that the mixing machines must never be turned on unless they have been checked to see that no-one is cleaning them or otherwise too near them. The transferred employee had not been told this. As a result of the accident, the transferred employee suffers nervous shock and depression which keep him off work for eight months.

Issues of investigation clearly identified and appropriately worded in the report