On June 23, 2012, a 30 year-old co-owner of a Thai restaurant (victim) was fatally crushed by a dumbwaiter car in the basement kitchen of his restaurant. The dumbwaiter was a wire-rope type lift or elevator for transporting household goods between the first floor food preparation area and the basement kitchen. There was a hoistway opening on each floor: it was a rectangle opening with a vertical sliding door. The incident occurred at 1:19 AM on a Sunday. At the time of the incident, the victim and several restaurant staff were working in the basement kitchen. A cook prepared an appetizer and placed it in the dumbwaiter car to send it to the upstairs dining area. The cook stepped aside while the victim was standing next to the hoistway door. At this moment, the manager upstairs yelled down the shaft asking about the appetizer. The victim leaned into the dumbwaiter shaft and told the manager that the appetizer was ready. According to the manager, she then looked down and saw the appetizer but did not see the victim in the shaft. She then pressed the UP button to activate the dumbwaiter car. The dumbwaiter car started moving up and the victim's head was caught between the upper frame of the access opening and the bottom shelf of the dumbwaiter car. The cook quickly moved the car downward to release the victim. The workers helped the victim to the floor. A 911 call was placed by the staff upstairs. The EMT services arrived at the site within minutes following the call. The victim was pronounced dead at the scene. The immediate cause of death was massive cranial-cerebral trauma. The American Society of Mechanical Engineers (ASME) specifies that all dumbwaiters have a hoistway door safety locking device. The locking device prevents the operation of the dumbwaiter unless all hoistway doors are in closed position. The dumbwaiter in this case did not have the locking device on the doors. CONTRIBUTING FACTORS: 1. The dumbwaiter did not have the hoistway door safety locking device to prevent it from being operated when the doors were open. 2. The restaurant owners were not aware of the ASME requirement of the hoistway door safety locking device. 3. The elevator company that serviced the dumbwaiter was not aware of the ASME requirement of the hoistway door safety locking device. 4. Workers used the dumbwaiter shaft to communicate between the upstairs and the basement kitchen. 5. High noise levels in the kitchen at the time of the incident made it harder to hear the upstairs staff. 6. Workers were not trained on the safety hazards associated with operating the dumbwaiter and how to operate it safely.