Abstract: At 2:00 p.m. on November 5, 2020, an employee was working at a sawmill. He was standing near lumber chains in the sorter area. Chains in a conveyor system moved lumber to a stacker. The chains or lines in the sorter area had all had updated equipment installed approximately two months earlier. Chain 1 did not have enough power to move more than three bundles of wood at a time. Too much weight was on the first chain, and it could not move lumber down the line to the stacker. Workers were moving lumber in the area to the chain 2 line. The conveyors were approximately 1 foot (300 mm) above ground level. The employee's foot was close to an unguarded lumber chain and sprocket. The employee was wearing steel toe boots. A coworker turned on the line to jog it in order to redistribute or move the lumber in the sorter. The front part of the employee's right foot was pulled into the chain and sprocket. The first two toes (the big toe and the one right next to it) were amputated. The employee was hospitalized. The equipment could have been locked out while employees performed this work. Employees could have locked out the equipment, moved the lumber so that only three bundles were on the first chain, and then restarted the equipment. Employee interviews indicated that employees were going into the area on a daily basis to move the lumber off of line 1. It had become an accepted practice for them not to lock out. There were as well two unguarded shafts that ran from motors to the chains and sprockets on the line that were at ground level. The fencing or expanded metal that went around areas outside of the machinery did not extend around the entire perimeter of the equipment. There were two areas with stairs where workers could enter the area. These two areas did not have fencing or expanded metal to prevent employees from entering the area.