On July 31, 1996, a 20-year-old laborer (the victim) at a recycling center died as a result of injuries he received after he was caught between the platen and the top of the baling chamber door of a vertical-downstroke baling machine. There were no eyewitnesses to the incident. Upon arrival at the work site, a co-worker noticed the victim leaning over the top of the baling chamber. When the victim did not return the co-worker's greeting, the co-worker went to investigate and found that the victim had been caught between the platen and the baling chamber door edge. He notified the local volunteer fire department/ emergency medical service which responded in 5 minutes. The victim was removed from the baling machine and transported to a local emergency room where he was pronounced dead. Subsequent examination by investigators revealed that the machine's safety gate interlock had been bypassed, allowing the machine to operate with the gate in the raised position. NIOSH investigators concluded that, to prevent similar occurrences, employers should: 1. ensure that all safety features on baling machines are functioning correctly; 2. ensure that employees, including management personnel, know and understand the importance of the machine's safety features; and, 3. consider instituting "buddy" rules so that workers do not perform potentially hazardous jobs alone.