Abstract: On April 6, 1991, Employee #1 had been seen on the top bar of the railings for the filler vat of a paper pulp beater at least twice between 4:00 and 6:00 p.m. At about 7:00 p.m., he was missing from his work station. Although he normally works the bulk liner vat, he had worked the filler vat many times before. The process requires that a forklift lift a bale of recycled paper to the top of the railing. The strapping is then cut and the paper is dumped into the vat. The employee assists the paper into the vat. In the vat are beater blades that break up the paper, shredding it to pulp. At about 7:45 p.m., the foreman was called and the process was stopped. At 8:00 p.m. the employee was found in the filler vat and was removed by a rescue team. Employee #1 died.