Abstract: ON SEPTEMBER 22, 1986, AT ABOUT 5 PM, EMPLOYEE #1 DECIDED TO CHECK ON A CHIP-N-SAW MACHINE, SN 4135-2, MADE BY CANADA CAR (PACIFIC DIVISION), HAWKER SIDDELEY CANADA LTD. HE DISCUSSED THE PROBLEM, INVOLVING HYDRAULIC VALVE CONTROLLERS, WITH THE CHIP-N-SAW OPERATOR, THEN HAD HIM SHUT THE MACHINE OFF. HE CHECKED THE INFEED SHIFT HYDRAULIC COMPONENT (IN A CABINET), THEN WALKED THROUGH A 14 INCH OPENING BETWEEN THE INFEED CHAIN AND THE CHIP-N-SAW ENTRANCE TO CHECK VALVES ON THE WEST SIDE (OUT OF SIGHT OF THE OPERATOR). AFTER ABOUT A MINUTE, EMPLOYEE #1 LEANED THROUGH THE 14 INCH OPENING AND HAND SIGNALED THE OPERATOR TO START THE CHIP-N-SAW. AS THERE WAS A LOG ALREADY IN THE CHIP-N-SAW, THE OPERATOR FOLLOWED THIS LOG BY EYE, OUT OF THE CHIP-N-SAW AND THROUGH THE BANDSAW, UNTIL THE LOG WAS CLEAR. THE OPERATOR THEN LOOKED BACK TO HIS LEFT AND SAW EMPLOYEE #1 STARTING TO ENTER THE 14 INCH ENTRANCE TO THE CHIP-N-SAW. A LOG FROM THE INFEED CONVEYOR WAS ALREADY ON EMPLOYEE #1'S BACK. THE OPERATOR SHUT DOWN THE EQUIPMENT. TO FREE EMPLOYEE #1, THE LOG WAS PUSHED BACK OUT ONTO THE INFEED CONVEYORS. EMPLOYEE #1 SUSTAINED FATAL CUTS AND LACERATIONS TO HIS FOREHEAD. EMPLOYEE #1 FAILED TO LOCK OUT POWER TO THE CHIP-N-SAW MACHINE BEFORE ATTEMPTING REPAIRS.