Abstract: At 8:00 p.m. on March 1, 2019, Employee #1 was operating the Automatic Die Cutting Machine ExcelC-106E, Serial Number 1470008, printing special orders. The employee had completed three orders using 9 inch by 25 inch paper. The next order required larger paper, 28 inch by 40 inch. In order to perform the new order, the employee needed to remove some parts in the delivery section. Using his hand tools, Employee #1 began to make adjustments to the delivery section of the machine while it was still engaged. A coworker became aware of noises coming from the machine, indicating a jam. The coworker walked toward the machine and saw that Employee #1 had become stuck in the machine. The coworker called emergency services, and paramedics responded quickly. Employee #1 sustained head injuries caused by the moving bars and was killed.