Abstract: Employee #1 was programming a job on a Mazak Quick Turn HP Computer Numerical Control machine, a type of metal lathe that runs completely automatically once programmed. The machine was built in 1998 and had several built-in safety features, one of which is an electronic barrier that will not allow a tool to contact the lathe chuck when the feature is enabled. It can be disabled, or bypassed, by pushing a button on the control panel when programming. It can also be disabled by the programming process itself. The machine also has a sliding door that encloses the point of operation that is interlocked when the machine is in automatic mode, but not while programming. Employee #1 made an error in programming the machine, which allowed a tool to strike the chuck when the tool holder indexed. He had the chuck barrier disabled and the sliding door was open. When the tool holder indexed, a cutting tool contacted the revolving chuck, causing the tool to be ejected from the machine, striking Employee #1 in the center of the forehead, causing his death.