Abstract: At 6:30 a.m. on May 9, 2023, Employee #1, a machine operator, was setting up an extrusion line threading material through rollers at roller station 1 of the line. A step of the set up involves employees threading, by hand, the material through roll stations (pull stations). The rollers of the roll station are in operation/moving during thread up/set up. The machine is not turned off or shut down. The rolls are programmed to turn/rotate at certain speeds so the desired end product is satisfactory and so the fibers don't break or wrap up. Speeds of the rollers at roll station 1 were programmed to be 96 feet per minute (fpm). There is an interlocked physical safety gate/door at roll station 1 located at the front of the rollers, where the employees stand to guide the tow through the rollers during set up/thread up. The door is opened or in the raised position while employees thread the tow through the rollers at the roll station. Employee #1, machine operator, was assisting with setting up the 2A fiber extrusion line. Employee #1 was in training and assisted with set up and treading the machine prior to and was observing the rollers at roller station 1, when employee 1 became caught in or between the material and rollers, resulting in traumatic head injuries. Employee #1 was killed. The event occurred indoors, and weather was likely not a factor contributing to the event. Machine guarding that did not fully protect employees from moving machinery, ingoing nip points, rotating parts, and crushing hazards and not utilizing hazardous energy control procedures are factors that likely contributed to the event.