Abstract: At 11:35 a.m. on January 16th, 2016, employees at a distribution center were returning from lunch in the break room when they heard the alarm going off on an International Press and Shear horizontal auto-tie baler, Model #AT-865-HS-100, Serial #3166. Two employees from the maintenance department went to see why the alarm was going off and saw Employee #1 slumped over in the baler. Employee #1 had been decapitated and was caught in a two foot by two foot hole that had been cut in the side of the baler, exposing moving parts of the gathering ram. They discovered the machine had not been locked out. The baler runs on an automatic cycle mode and will run continuously as long as there is enough material in the hopper. All of the original guards were in place, but the modified hole did not have any type of guard over it.