Abstract: A bearing was failing in an auger system used to convey sugar beet pulp at a pelletizing operation. The night shift crew removed a stairway from a location above the ends of the adjoining transfer point on the augers and placed a warning tape at the stairway entrance. When the day crew assembled to assess the problem and begin the system shutdown, they did not lock out the system. A workman removed the warning tape from the top of the stair access point and another worker removed the cover plate to allow visual access to the bearing location. When Employee #1, the shift supervisor, walked into the area at the upper level and approached the location where the stairs were normally located, he stepped directly into the end of the auger that had a kicker attached. (The kicker transfers the product horizontally from one auger to the next.) Employee #1's right leg was drawn in by the kicker, and forced into the next auger. His foot/leg were amputated and the entire leg was severely crushed. His pelvis and lower internal organs were crushed: Employee #1 died of extensive hemorrhaging.