Abstract: On September 1, 2010, Employee #1, of Transworld Plastic Films Incorporated, was clearing excess film from a Black Clawson Enveloper Roll Changer, an indexing machine for film. The indexing machine was at the end of a production line. The finished product would be rolled into thin sheets of film onto the roll. When each run was complete, the cut off blade would slide the film and then a new roll would start on the next roller. Excess film was collected with the use of suction funnel located on either side of the roll. It was reported that the suction funnels would occasionally get jammed with excess film, and employees would unjam the film while the machine was in operation. Employee #1 cleared the excess film, when he was caught between a cut-off blade and structural brace of the Black Clawson Enveloper Roll Changer. He was killed. Prior to the incident, the employer had not developed, implemented, or utilized a lock out/tag out program. Employee #1 had not received any lock out/tag out training. There was no personnel protective equipment necessary for this particular operation.