Abstract: On June 5, 2003, an employee of United Paper Stock Company Inc. was operating a horizontal paper baling machine. The machine was operating in automatic mode so the hydraulic ram moves in and out continuously. There are limit switches at each end to signal the machine to return in the other direction. Apparently the lever arm on one of the limit switches had bent so when the ram opened fully, it missed the arm on the limit switch. Therefore, the ram did not close. The machine stopped. The employee decided to open the guard and reach into the machine to try to bend the lever arm back into position. He kept the machine in automatic mode and did not lock out the power. When he moved the lever arm, this signaled the ram to close. The ram closed and amputated the employee's head and right arm.