Abstract: At approximately 1:00 p.m. on January 21, 1991, Employee #1, an oiler in a sawmill, was oiling and greasing moving parts on sawmill machinery. His routine consisted of first oiling the parts that he could safely reach while the machinery was operating. Then, at lunch time, when the mill was shut down, he would oil the parts he couldn't reach while the mill was running. During lunch time, all the equipment was turned off in the sawyer's control cab, but not locked out. It was common practice for the sawyer to start up the machinery 15 to 20 minutes before 1:00 p.m. so the mill would be running when the employees returned from lunch. On the day of the accident, the sawyer checked the trim saw area, the portion of the mill Employee #1 typically did last before he went to lunch, and did not see the employee. He turned on the machinery, unaware that the employee was under the saw platform near the tail spool of the slab conveyors. The employee's upper arm was caught between the tail spool and the conveyor belt. He was killed instantly.