Abstract: At approximately 8:20 a.m. on December 15, 2008, Employee #1, the machine operator, was preparing for a job on the F.L. Smithe Model Number 5 envelope machine. At the same time, a coworker, an adjuster, was completing his assigned set up tasks on the machine for the production run. The machine was running at the time of the accident in order for the coworker to set the timing of the various components of the machine. Employee #1 was standing near the Gum Box, a pan in which glue is placed, when her scarf became entangled in a horizontal main drive shaft whose unguarded exposed portion measured 12.5-in. long and was 27-in. above the floor. Employee #1 was pulled down in to the rotating shaft. The coworker heard a noise and looked up to see that Employee #1 was no longer visible. The coworker shut down the machine and walked to the west side of the machine and witnessed Employee #1 on the ground. The coworker called a nearby manager who reversed the machine to reveal Employee #1's scarf was wrapped around the drive shaft. Employee #1's scarf was cut and emergency response was called. Employee #1 was transported to the hospital where she was pronounced dead. An autopsy by the Medical Examiner revealed the death was caused by multiple injuries to Employee #1's upper extremities.