Abstract: On November 12, 2008, Employee #1, with the Alabama River Newsprint Company, entered a winder machine to remove materials that had fallen between the set roll and the rear drum. Prior to entering the winder, he failed to follow the company's mandatory lockout procedure of turning the run-service key to the service setting, removing the key, and placing it in his pocket. The control room operator was unaware that Employee #1 was inside the winder. When the operator activated the winder, he noticed that the power-on light failed to activate. Upon investigation, he found Employee #1 lying across the set roll, face-down. He was killed.