On January 17, 2006, a 52-year-old millwright (the victim) was fatally injured when he was pinned between the feed rolls of a debarker as he was welding additional metal to the teeth on the feed rolls. The victim had locked out two electrical disconnects in the debarking room before beginning his work, but he had not locked out all electrical disconnects and had not shut off and locked out the air line to the machine. As the victim welded, he leaned forward and placed his head between the upper and lower feed rolls to reach areas that required more metal. The air pressure on the rolls automatically cycled and the feed rolls closed over the victim's head. The victim had been working alone. His supervisor had left the area to check on another machine. When the supervisor returned to the area about 20 to 30 minutes after he had last seen the victim, he found that the victim had been caught in the machine. The supervisor called on the company radio for help and for someone to call 911. He then turned off the air line. When he returned, he and other employees used a chain jack, commonly referred to as a "come-along," to lift the upper feed roll off of the victim. They removed him from the machine and placed him on the floor next to the machine. Emergency medical services (EMS) personnel arrived approximately 20 minutes after receiving the 911 call and attempted to do cardiopulmonary resuscitation but to no effect. They called the coroner who came to the site and pronounced the victim dead. NIOSH investigators concluded that, to help prevent similar occurrences, employers should: 1. ensure that hazardous energy control safety procedures clearly identify all potential sources of energy for each machine and that the location and the method for control is clearly identified. Workers should be routinely trained on the procedures; 2. Ensure that all hazardous energy, including pneumatic energy, is locked out, and any stored energy is released before repair work begins; 3. follow the equipment manufacturers' recommendations for removal, maintenance, repair, and/or replacement of machine parts; 4. Ensure that employees are adequately trained and supervised when assigned to perform new, infrequent, or dangerous tasks; 5. contact the equipment manufacturer for assistance in redesigning machine systems to reduce the number of lockouts needed to render the equipment safe for repair and maintenance.