Abstract: At 12:45 a.m. on October 30, 2019, an employee was working as a forging machine operator for a firm that manufactured iron products for the water and wastewater industries. They made such products as ductile iron compact and full body mechanical joint (MJ) fittings, full body flange fittings, compact push-on fittings, fabricator products, accessories, and a complete line of coatings and linings including fusion bonded epoxy and ceramic epoxy. The employee was working on the firm's EMI line. He was on back side of the EMI line, preparing molds. Some employees on the EMI line stood on the back side of the line as part of their normal work activities. This was the side opposite the control panel and emergency shut-off. Mold carriages moved along the line in increments of one carriage length at a time. An alarm sounded immediately prior to the movement of the line. At the time of the incident, the employees were finishing their shift. The employee dropped his hard hat and water bottle under the carriage line. As he reached into the open area under the line, the machine activated, and the carriages moved to their next position. A carriage struck the employee in the head and upper torso. The emergency stop was activated. The other workers present pulled the employee to the front side of the line and called for help. The employee had suffered a skull fracture. He was hospitalized. Machine guarding had been previously in place, but the guards were not installed at the time of the incident. The safety manager stated that the guards were known to periodically fall out of the supports holding them in place, exposing the opening below the carriages. The employee stated that it was his first time to work on the back side of the line, and that machine guards were not in place at the start of the shift.