Abstract: At approximately 8:45 a.m. on February 15, 2013, Employee #1 was working as a machine operator for a firm that manufactured aerospace equipment. He was regarded as "an expert with tremendous experience," and he was an instructor at a technical institute. The incident occurred in the morning, just as Employee #1 began lathe operations for the day. He was operating a Tarnow horizontal metal lathe to face or machine a stainless steel containment vessel known as "the flask." This flask was mounted or secured on the lathe between the jaws of the chuck and a live center tail stock. Employee #1 set the lathe's operating speed to 1,000 rpm instead of 250 rpm. As it was being machined, the flask became loose from between the chuck and tailstock, spun off the lathe, and struck Employee #1 in the top back of his head. He was found slumped in a sitting position against a cabinet. He had lost consciousness. Emergency medical services were called, and Employee #1 was immediately rushed to the emergency section of nearby Highland Hospital. He died on February 20, 2013. Based upon the interviews conducted and documentation developed during the course of an investigation, the conclusion was that the employer did not provide a guard or guarding system on the Tarnow lathe. Employee #1 was exposed to the rotating parts of the machine, including the chuck and stock. Had an appropriate guard been provided, this incident could have been prevented.