Abstract: Employee #1, a automated palletizer operator, was clearing a jam on an in-feed chain conveyor caused by a product spill on the in-feed conveyor. He turned off the conveyor, which was not interlocked with the palletizer, and began to straighten up the spilled material. After rearranging the product on the in-feed line, he climbed onto the conveyor and physically pushed the product down the conveyor line into the point of operation of the palletizer. The palletizer had been programmed to activate when microswitches mounted along the conveyor, which counted the product as it moved into the point of operation, were tripped. The containers of product and Employee #1's feet inadvertently set off the microswitches and actuated the palletizer's stack push arm. This sudden and unexpected movement resulted in Employee #1 becoming pinned between the stack pusher and a vertical guidepost. He was killed. No lockout procedure had been used.