Abstract: At approximately 9:22 p.m. on January 13, 2004, Employee #1 was working alone operating a Paolo Orizio circular knitting machine, Serial Number 109216809. This machine operated by drawing thread from separate spools through guides into the knitting head where a series of knitting needles in a circular retaining ring knitted the thread into fabric. The guides that the threads travel through contained sensors with interlocks that stopped the machine in the event that a knot or broken thread was detected. After being knitted, the fabric would be taken up into a roll inside the bottom of the machine by the take-up assembly, which moved in a circular motion and was enclosed by a set of interlocked metal gates. Employee #1 entered the take-up area to adjust the spool of fabric which was rolling incorrectly or had fallen off the spool. It was in this take-up assembly that Employee #1 was found in between the shoulder of the take-up assembly and the electrical panel. He was killed. At the time of inspection, one of the machine's gates was open and a thread spool rod was found wedged into the access door interlock control switch. A knitting needle was also wedged into the machine's start button retaining it in the completely depressed position. According to other employees interviewed, the thread guide sensors of the knitting machines would often trip even if the thread was feeding properly, causing the machines to stop frequently. To quell this, it was common to insert a knitting needle between the start button and button collar of the machine's controls to retain the button in the completely depressed position, allowing the machines to keep running during these "false alarms." Employees also stated that thread spool rods were commonly inserted into the interlock latches of the machine gates so that the machines would run with the gates open affording a better view of the fabric roll but that the interlock on the machine involved in the accident did not work. Based on management and employee interviews, it was established that employees are required, as part of their normal duties, to enter the take-up assembly area of these circular knit machines to adjust, install, and remove the fabric rolls when they begin to spool incorrectly or have reached the desired size. According to the company president, the procedure for entering the take-up assembly area of the machines was communicated verbally to employees and describes first stopping the machine by either pressing the stop button, flipping the switch at the panel, or by pulling one of the interlocked thread guides to the down position before entering the machine. Locking and tagging out electrical and mechanical energy sources were not included in the procedures and energy control could not be utilized effectively with any of the described methods. It was determined that no written energy control procedures were established on site at the time of inspection and effective energy control procedures were not utilized during periods of adjusting, repairing, and servicing the take-up assembly of the circular knitting machines.