Abstract: At approximately 10:00 p.m. on October 25, 1990, Employee #1 was working in a cotton gin operation that included both day and night shifts. The addition of a semi-automatic wire tying unit had eliminated the bagger position, and those duties were reassigned to the assistant pressman. The training of the day shift on this new procedure was conducted by management. Training of the night shift was the responsibility of the day and night ginners, and consisted of 10 to 15 minutes of observation. Subsequently, and with the tacit approval of the ginner, the bagging procedure was modified so that the sampler would take a shortcut through a 9 in. opening between the scales and the belt conveyor to reach the far side of the auto-bagger unit. Employee #1 and the head pressman installed a bag on the auto-bagger, then tied, tagged, and weighed the bale. During transactions between bales, Employee #1 was crushed against a structural member of the auto-bagger unit by a moving bale of cotton. He was killed. The bale that struck Employee #1 was being pushed off the scale by another bale coming off the auto-bagger. This was the normal operating procedure during the night shift.