A mechanical supervisor in a paper mill – with 23 years of experience in the industry – was inspecting a machine with two other supervisors. While repairs were being contemplated, the machine was left running and an easily movable guardrailing was left out of position.

The supervisor moved too close to a rotating drive shaft when the back of his loose woolen sweater became entangled in the coupling. The machine picked him up and rotated him around the shaft a number of times. He suffered broken ribs and the amputation of his left leg below the knee. He died two weeks later from his injuries.

The coroner investigating the case noted that the company had no policy of stopping motors when the shielding barriers were removed. He also noted that both managers and production workers at this company had become too complacent in getting too close to this potentially dangerous machinery.

The coroner recommended that company standards be set up for safe shielding of hazardous manufacturing equipment, that emergency lockout switches be installed near the hazardous areas. The coroner noted that all three supervisors were wearing similar loose clothing and that the company should strictly enforce a clothing policy for all workers.