Abstract: At approximately 11:30 a.m. on February 12, 2006, Employee #1, a 56-year old steel manufacturer, was using an oxyacetylene torch to cut the tail end of a steel coil sheet. The sheet measured approximately 1-inch thick by 17-feet long and was to be used for scrap--melted down and reprocessed in an electric arc furnace. As Employee #1 completed cutting the scrap metal, which was done at an angle, a strip weighing 3,400 lbs. flipped up and struck Employee #1. The strip then released along the cut and pinned Employee #1 to the ground, severely crushing and killing him. The accident investigation revealed that Employee #1 was wearing the necessary personal protective equipment, which included: a safety hat, a welder's shield, thermal gloves, and safety shoes. Additionally, the employer had a job safety analysis (JSA) procedure in place for the cutting of scrap steel, which Employee #1 was trained in for his work area and followed while cutting the scrap steel.