Abstract: Employee #1 and some coworkers were troubleshooting a malfunctioning conveyor/sump tank assembly, or quench tank. Employee #1 climbed atop the quench tank and was looking down at the chain that had come off of the sprockets of the turnaround shaft. He had his left knee on the iron guard and his right foot on the middle of the shaft, facing the north side of the machine. As coworkers were prying on the chain to put it back on the northern sprocket, Employee #1 shouted, "The chain is moving". As the chain came toward him, a drag flight apparently caught his lower right leg and pulled it down between the guard and the shaft. Employee #1 flipped over so that his left leg was resting on the south side of the tank, facing upward, and he was pulled down through the space between the shaft and the guard. He died of compressional asphyxia in the quench tank mechanism. The machine had not been locked out and tagged out.