On April 18, 1997, a 37-year-old male maintenance electrician (the victim) died when his lower torso was crushed between the nip barrier (a wire-mesh gate) and the upper frame of a paper rewinder machine at a paper -manufacturing facility. Without first de-energizing, locking out, and tagging the machine, the victim began to replace the arm for the limit switch that controlled upward movement of the nip barrier. He climbed an 8-foot stepladder to access the top of the machine where the switch was located, and leaned into the 16-inch opening between the top of the nip barrier and the upper frame of the machine. Co-workers observed him reaching with a screwdriver into the area where the switch was located. Apparently he inadvertently activated the limit switch and the nip barrier raised, carrying the victim and the stepladder upward and compressing both between the nip barrier and the upper frame of the machine. NIOSH investigators concluded that, in order to prevent similar incidents, employers should: ensure that maintenance workers follow established lockout/tagout procedures for control of hazardous energy; conduct regular worksite evaluations to ensure adherence to established procedures for control of hazardous energy; train production workers and other non -maintenance workers to recognize potential workplace hazards and participate actively in workplace safety.