Abstract: At 11:00 a.m. on March 8, 2006, Employee #1, a machine operator with a precision machine shop, was operating an SH-63 Mori Seike Horizontal C&C Milling Machine to cut automobile wheels. After installing a wheel blank, he called his supervisor to program the machine for the cut. In the interim, Employee #1 went inside the machine to retrieve a wrench he had dropped. The supervisor then manually closed the machine door and pushed the start button. When he heard screaming, the supervisor pushed the hold button, opened the door, and found Employee #1 behind the chuck with both feet and legs caught in the running machine. Employee #1 sustained serious injuries, resulting in hospitalization, surgeries and amputation of his right foot. He later died of his injuries.