Abstract: Employee #1 was preparing to make a cut on a steel pipe elbow that was approximately 56 in. long by 20 1/2 in. in diameter and estimated to weigh 1,500 to 2,000 lb. The work piece was held in a steel cradle that was mounted on the table of a Toshiba Shibaura CNC vertical mill #7838. The work piece broke free from the cradle, apparently from excessive machine rpm, and was thrown from the machine. Employee #1, who was standing at a moveable panel approximately 4 ft away, was struck and suffered multiple injuries to the head, chest, and abdomen from which he died. This mill was equipped with an override control that controlled the table rpm. When turned down past the lowest setting (50 percent of maximum cutting rpm) the machine would automatically speed up to the maximum rpm. This is assumed to be the cause of the excessive rpm.