Abstract: Every morning between 6:00 a.m. and 6:30 a.m., two employees would change the chipper knives while coworkers randomly arrived for work and sat around waiting for the chipper to be readied so the mill could start up. On November 16, 2004, this routine continued, but waiting coworkers noticed that the electric infrared heater, located on the east side of a double-sided panel board, on which they relied to warm their lunches would not come on. One of the waiting coworkers took it upon himself to turn on what he thought was the main power switch for the infrared heater. This coworker walked around to the west side of the panel board and threw up the lever on the right side of a 600-volt, 400-ampere, General Electric Heavy Duty Safety Switch. The coworker actually turned on the power to the chipper's 300-horsepower motor. Employee #1's head was crushed, killing him instantly. Neither of the men changing the chipper knives had used a lockout device.