Abstract: Employee #1, a maintenance person, was assigned to check the #3 Duo mill for various problems. The mill was starting up by itself and areas were going to ground. When one problem was fixed, other problems would arise. The feed reel, which had a steel coil on it, had started up by itself and was running in reverse. The coil was removed by a tractor operator. The feed reel's mandrel was covered with four segments of metal weighing about 150 to 175 lb each. Strips of wedges secured the segments. When Employee #1 and a coworker, who had been working in the Duo mill area, finished all the work they could do because the mill was down, they took a break and sat on a wooden bench about 50 ft from the Duo mill reel. At approximately 9:45 a.m., while further checks were being conducted, the feed reel started up by itself and ran in reverse at a very high speed. A segment broke loose and flew off, traveling about 63 ft across the mill and 45 to 50 ft into the air before striking near the top of the mill's corrugated wall. The segment bounced off the wall and traveled down, where it struck metal piping along the wall, and bounced back out into the mill area. Employee #1, who had seen another piece of metal fly by in front of him, was running away from the bench area when he was struck in the back by the flying metal segment. He sustained massive injuries and died. Since the maintenance employees were not working on the reel side, they had not given any thought to placing a metal sleeve over the segments on the reel as a protective measure. Since they knew that the reel had started up by itself and run in reverse with the coil on the reel, they knew that a problem existed and that the same thing could happen again; thus, they should have installed the metal protective sleeve over the segments.