At a shake and shingle mill, a young worker was sawing mostly grade 3 and 4 shakes using a head saw. While sawing a cedar block, the sawyer noticed that it was badly checked. He stopped the carriage with the floor brake pedal. He then kicked the cedar block to break off a damaged section. This action jarred the carriage, which then unexpectedly moved forward. The worker's foot was drawn into the spinning saw blade. His foot was nearly amputated.

The pedal brake has a rocker switch with a spring that latches the pedal in the ON or OFF position. However, in this incident the spring disengaged from ON but did not latch into the OFF position. Although the carriage was stopped, the spring was positioned between ON and OFF. With a light tap or even vibrations from the head saw, the brake pedal could then default into the ON position. To fully engage the brake on a rocker switch, the operator must use enough force to latch the spring, and the floor must be clear of debris that could limit the pedal's movement.

• Maintain equipment according to the manufacturer's instructions. Ensure that there is a strong spring controlling the ON/OFF switch and that the switch is functioning correctly.
• Develop safe procedures for sawing poor quality blocks. The procedures must be specific for the job. Train workers to follow these procedures.
• Supervise workers when they start a job and also when they operate the equipment at full production speed. Ensure that production demands do not result in unsafe work habits.
• Keep the areas around equipment clean so that debris does not interfere with the safe operation of foot controls.