Abstract: At approximately 8:05 a.m. on December 3, 2004, Employee #1 was monitoring the operation of a trim saw that had its shaft rotating. For an unknown reason, Employee #1 went into the saw and shaft area, near its out-feed conveyor, by bending under the guard. The guard was installed around the back side of the saw and conveyor area and was 50 inches above the ground. The shaft on that end was equipped with timing lugs and was not guarded. Employee #1's sleeve from his jacket got caught on one of the lugs, pulling both of his arms into the shaft of the saw. He was discovered caught in the conveyor, which had stopped with both of his arms amputated. Employee #1 was transported to a hospital where he died the next day.