Washington Report Details Fatal Paper Mill Machine Accident
Investigators identified inadequate machine guarding and lockout/tagout failures in a worker's death.
- By Stasia DeMarco
- Nov 03, 2026
A 32-year-old paper mill operator was killed while attempting to clear a jam in a packaging machine, according to a newly released report from the Washington State Department of Labor & Industries (L&I).
The report, published Nov. 2, examines a March 8, 2024, incident involving a machine known as a unitizer, which stacks cardboard boxes on a conveyor for shipping. Investigators identified inadequate machine guarding, failure to follow lockout/tagout procedures and insufficient supervision as contributing factors.
The operator worked for the company for four years and had been a full-time machine operator for three months. He was working alone in an isolated area when the unitizer jammed shortly after his shift began.
According to the report, the operator contacted supervisors four times over about 45 minutes for help. During his final call, he reported that the machine's stacking arms were stuck on boxes and that he did not know how to clear the unusual jam.
While waiting for assistance, the operator entered the machine's perimeter gate and attempted to clear the obstruction. Approximately 35 minutes after his final call, coworkers discovered him unresponsive, pinned between the stacking arms and conveyor. Emergency responders pronounced him dead at the scene.
Investigators found that the operator entered the machine without first de-energizing it, despite having received machine-specific lockout/tagout training. The report also determined that the employer failed to consistently enforce its hazardous energy control procedures.
Machine guarding deficiencies were another significant concern. The employer permanently removed manufacturer-installed guards in 2017 when it installed a perimeter gate. Three job hazard assessments conducted between 2016 and 2021 identified inadequate guarding and recommended interlocking doors that would stop the machine when the gate was opened.
Although the employer approved the improvements several months before the incident, installation work had only begun two weeks before the worker's death.
The Washington Fatality Assessment and Control Evaluation (FACE) program recommends that employers evaluate machine safeguarding systems, including interlocked barriers, light curtains, emergency stops and warning devices.
Investigators also emphasized the importance of monitoring compliance with hazardous energy control procedures, particularly among employees working alone in isolated areas.
The report highlights the need for employers to address identified machine hazards promptly, maintain effective guarding and ensure that lockout/tagout procedures are consistently followed.
The FACE report is based on preliminary information and does not represent a final determination of the incident's cause.
About the Author
Stasia DeMarco is the content editor of Occupational Health & Safety.