Abstract: AT APPROXIMATELY 3 AM ON JULY 30, 1986, EMPLOYEE #1 WAS DUMPING A BALE OF SHREDDED PAPER INTO A FILLER-PULPER MACHINE. THE FILLER-PULPER MACHINE IS A VAT, LOCATED BELOW FLOOR LEVEL, WHICH IS 20 FEET IN DIAMETER, 16 FEET DEEP, AND IS EQUIPPED WITH A MIXING BLADE AT THE BOTTOM. EMPLOYEE #1 WAS USING A FORKLIFT TRUCK TO TRANSPORT BALES OF SHREDDED PAPER TO THE RIM OF THE PULPER. HE WOULD DISMOUNT THE FORKLIFT AND CUT THE WIRES HOLDING THE BALE TOGETHER, THEN REMOUNT THE FORKLIFT AND PUSH THE LOOSE BALE INTO AN UNGUARDED 6 FOOT, 6 INCH WIDE FLOOR OPENING. APPARENTLY, WHEN EMPLOYEE #1 WAS CUTTING THE WIRE ON ONE OF THE BALES HE FELL THROUGH THE FLOOR OPENING INTO THE PULPER. THE PULPER WAS FILLED TO THE TOP WITH WATER AND SHREDDED PAPER. THE PULPER OPERATES CONTINUOUSLY. EMPLOYEE #1, WHO HAD BEEN GIVEN 3 DAYS OF ON-THE-JOB TRAINING WITH THE PULPER, AND HAD WORKED ON HIS OWN ONLY ABOUT 4 DAYS, WAS KILLED.