Abstract: At 6:00 a.m. on March 16, 1987, Employee #1 and a setup machinist were setting up the Okuma lathe to cut a 4 in. by 12 in. pipe reducer to proper length and to make a weld level at each end. After the setup man had adjusted the lathe to the proper speed for this work (290 rpm), he put the speed lever in neutral and told Employee #1 to make the cuts. Instead of shifting the lever to low speed (290 rpm), Employee #1 shifted it to high speed (1,800 rpm). The setup machinist had turned and walked approximately 5 to 6 ft away when he heard the sound of the lathe operating at high speed and told Employee #1 to stop the lathe. Employee #1 immediately shifted the lever from 1,800 rpm down to 290 rpm. This rapid downshifting caused the chuck jaw bolts to shear off. The chuck jaw flew out and struck Employee #1 in the chest, killing him.