Abstract: At approximately 10:40 p.m. on July 23, 1997, Employee #1 was working alone in the back room of a supermarket, apparently trying to remove jammed cardboard from a vertical baling machine. A coworker walked in and found Employee #1 pulled up into the baler, with his head, arm, and shoulder caught between the top of the ram and the frame. The coworker called 911. The "jaws of life" were required to extricate Employee #1, who was pronounced dead at 11:10 p.m. The baler was taken out of service until OSHA investigators arrived. A service technician operated the baler, with its gate down, and it ran until the ram hit the cardboard, whereupon it stopped. This indicated that the baler was full, and wires needed to be tied around the bale so it could be ejected. At this time, several pieces of cardboard were also found jammed against the back wall of the baler. These jammed pieces are normally removed prior to baling, sometimes with the ram in the 'down' position and sometimes in the 'up' position. Employee #1 was likely doing this at the time of the accident. The baler had an interlock, but it only prevented the baler from operating with the gate up when the START button was pushed. Once the baler was in operation, the gate could be fully opened and the ram would stop its down cycle, and cycle up. The START button could also override the interlock, if constant pressure was applied to it, allowing the gate to be open while the ram was in the up or down stroke. The employer was cited for three general and four serious violations.