Abstract: The rewinder operator was operating the Camachine Rewinder with Employee #1, his assistant. The operator controlled the rewinder from a control panel. They were rewinding a 12 ft 1/2 in. wide roll of dryfelt paper into four rolls; each roll was 36 1/8 in. long. The operator ran the machine at about 1,250 ft per minute while rewinding the paper. Once completed, the rewound rolls were about 5 ft in diameter on a 13 ft long shaft. The total weight of the dryfelt paper rolls, including shaft and top rider roll, was about 7,000 lb. The operator slowed the rewinder to about 250 ft per minute. Employee #1 went to the 13 ft long by 5 ft wide by 3 ft 9 in. high eject table and taped two rolls of the rewound paper. The operator went to the eject table behind Employee #1 to tape the other two rolls of paper. The rewinder was in operation, but no one was at the control panel. While taping the rolls, Employee #1's foot went into the nip point between the bottom of the paper rolls and the driver rolls and was pulled under the rolls of paper. The operator left the eject table and turned the rewinder off, but only after the employee had gone through the machine. Employee #1 sustained multiple injuries when his entire body was crushed, killing him. There were no guards to prevent the employee from entering the nip point or the machine's other rotating parts. The company had been relying on work procedures to prevent employees from entering the machine. The company procedures required that the operator stop the rewinder once the rolls of paper were rewound. The assistant would then go to the eject table and tape the rolls of paper while the operator controlled the rolls with a jog button that rotated the rolls at 75 ft per minute and only while the spring loaded button was being pushed down. Interviews with the rewinder operators and their assistants found they were not trained to operate the machine as the company's procedures required them. Further investigation found that the company had not created written work procedures for operating the rewinder.