Abstract: Employee #1 was using a Cemco double-end boring machine with trim saws to cut wood. He had already cut many pieces that morning, using only the right trim saw blade. Just prior to the accident, a coworker set up the saw as required for the next series of cuts. He removed the guard, completed the preparations, and then reinstalled the guard, with three bolts holding it in place. A few minutes later, Employee #1 had resumed cutting wood strips when the aluminum saw guard broke off and a large piece of it struck him in the head. He was transported to the hospital, where he later died of blunt force trauma. The guard was held in place by three bolts, one of which was still in the machine holding a remaining piece of the guard as installed. Another bolt was in the piece that broke off, and the third was found in the sawdust on the floor. It was not known what caused the guard to break apart and fly off the machine, nor was it clear whether the bolts had been properly secured.