Abstract: On November 4, 1991, Employee #1 was working in the finishing department of a paper mill when she was struck by the descending gate of a roll lowerator. She fell down the hoistway of the material handling device to the floor, then apparently struck the material tray as it descended to the floor below, where the tray automatically tilted to eject the transfer roll. At some point before the lowerator tray returned to the finishing department, the employee apparently fell 21 ft, through openings between the tray and open framework of the hoistway, to the elevator pit below the finishing floor. She sustained a head injury and a puncture wound to her abdomen, and was killed. There were no witnesses. The roll lowerator, a common piece of equipment at paper mills, was in semi-automatic mode. At some point, the employee may have been caught between its components. The coroner's report is pending.