Abstract: At 2:35 p.m. on March 20, 2009, Employee #1 was using an air hose to clean out debris from inside a Ballegraaf Recycling paper baler, Model Number 120S, while the machine was in manual mode. Employee #1 had worked all day as a sorter in another department. At the end of the shift, Employee #2 would randomly select employees to clean out the baler for paper and debris. This was a daily routine for the company. Employee #2 had received a phone call before the cleaning had begun. Employee #2 had pressed the red button (an emergency "shut off" switch) to shut the baler off and did not lockout the baler before leaving the area to go and answer the phone call. In the meantime, Employee #1 had placed himself in the baler and began cleaning it with the air hose. Employee #2 returned and activated the baler ram to the forward position for cleaning. He did not know that Employee #1 was in the baler. Employee #1 was crushed. Employee #3, who was in the area, noticed that the access door was open and that the body of Employee #1 was lying in the access door of the baler and on the floor. Emergency response was called, and Employee #1 was pronounced dead on the scene.