Abstract: Employee #1 was in a 3-ft by 4-ft work area of a vertical edger removing a 5-in.-diameter hydraulic cylinder with a 3-1/2-in.-diameter shaft under 2,500 psi, using a pipe wrench to unscrew the shaft. The pipe wrench was 48 in. long with a piece of 30-in.-diameter pipe level over the handle to provide additional leverage. A coworker was outside of the opening, pushing on the wrench with both feet. It was a slow procedure and the wrench was getting harder to move. The shaft was just over 4 in. out of the clevis when it broke free. The wrench, which was still gripped by the shaft retracted into the cylinder, pinning Employee #1 to the mill housing by the wrench handle. Employee #1 could not breathe. A cutting torch was used to free Employee #1, who at that point was not breathing. Employee #1 was in the hospital from December 7, 1985, to February 12, 1986, when he died from vascular collapse. Apparently, the machine's hydraulic system was not locked out and the lines were not bled.