Abstract: On November 2, 2007, the separator carriage on a Mornap #66 machine jammed. This machine is used to construct napkins, fold them and package them. In an effort to un-jam the machine Employee # 1 pushed the start button of the separator carriage of the machine and inserted an ink pen through holes in the sleeve surrounding the button. The ink pen held the button in so that power was provided to the separator carriage. Employee #1 then removed an access panel and crawled underneath the carriage to attempt to un-jam the carriage. Employee #1 did not lockout the equipment before entering into the area under the machine. While Employee #1 was under the machine, the separator carriage became free and struck Employee # 1 in the throat. Employee # 1 was taken to the hospital in a coma and was placed on life-support. On November 8, 2007, around 9:00 am Employee # 1 expired.