INCIDENT HIGHLIGHTS

DATE:

December 05, 2020

TIME:

02:30 AM

VICTIM:

Age: 27

Sex: Male

Occupation: Autoclave 

Operator 

INDUSTRY/NAICS CODE:

327215

EMPLOYER:

Glass Manufacturer

SAFETY & TRAINING:

Job Specific Safety Training

SCENE:

Business Parking Lot

LOCATION:

Kentucky

EVENT TYPE:

Suicide

REPORT#: 20KY075 REPORT DATE: 7/14/2021 

Manufacturing Worker Dies by Suicide

SUMMARY

On Saturday, December 5, 2020, following a dispute with his domestic 

partner, a 27-year-old male autoclave operator exited his employer’s

facility, proceeded to the parking lot and entered his vehicle. While inside 

the vehicle, the individual died by suicide with a gun.

READ THE FULL REPORT> (p.5)

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• Domestic dispute

LEARN MORE> (p.6)

RECOMMENDATIONS

Kentucky FACE investigators concluded that, to help prevent similar 

occurrences, employers should:

• Consider providing suicide prevention training to all employees.

• Implement a system for reaching out to individuals who exhibit signs of

distress, including suicidal ideation

• Include mental health screenings during annual wellness checks

• Consider promoting and ensuring mental health services are readily

available for employees, including those who exhibit behaviors

associated with self-harm.

• Consider providing resources for immediate and long-term suicide

postvention.

• Consider shift separation for employees who are engaged in a

domestic partnership.

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Page 2

Fatality Assessment and Control Evaluation (FACE) Program

This case report was developed to draw the attention of employers and employees to a serious safety hazard and is based on

preliminary data only. This publication does not represent final determinations regarding the nature of the incident, cause of the

injury, or fault of employer, employee, or any party involved.

This Case report was developed by the Kentucky Fatality Assessment and Control Evaluation (FACE) Program. Kentucky FACE is a

NIOSH-funded occupational fatality surveillance program with the goal of preventing fatal work injuries by studying the worker, the

work environment, and the role of management, engineering, and behavioral changes in preventing future injuries. The FACE

program is located in the Kentucky Injury Prevention and Research Center (KIPRC). KIPRC is a bona fide agent for the Kentucky

Department for Public Health.

Email: Kyfaceprogram@uky.edu

Twitter: http://twitter.com/KYFACEProgram

Facebook: https://www.facebook.com/Kyfaceprogram/
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INTRODUCTION

On Saturday, December 05, 2020, an autoclave operator (decedent) left his shift early, exited the factory, and proceeded 

to his vehicle which was located in the factory’s parking lot. After entering the vehicle, the victim moved closer to the

entry of the facility and parked. Sometime later, the victim died by a single self-inflicted gunshot wound to the head. 

EMPLOYERS

The employer - which was founded in 1986 and is located in five states, Mexico, and Canada - manufactures and markets 

glass and glazing products for architectural and automotive markets. The company employs over 28,000 workers in 

North America, 315 of whom are located at the Kentucky plant. 

WRITTEN SAFETY PROGRAMS and TRAINING

A company representative stated that the company has a well-established employee orientation program and employee 

manual. New employees are required to attend an on-site orientation which covers the policies and procedures and 

OSHA required training. After orientation, employees receive job-specific training based on the position for which they 

had been hired. This specific training, which lasts approximately two weeks, can include machine functionality, proper 

operation, safety practices, and forklift operation. 

WORKER INFORMATION

The decedent was a 27-year-old white male who was not married and had no children. The victim attained a high school 

diploma and had worked for the involved company for the last seven years. 

INCIDENT SCENE

The incident occurred in the parking lot located on the premises of the auto glass manufacturing facility. The facility 

itself is fenced and gated, and the parking lot sits just south of the gated area. A security guard shack is located on the 

west side of the parking lot to monitor the access road that leads to the gated facility and is staffed at all times. 

Employees arriving and departing pass through the turnstiles located on the northeast side of the parking lot via a 

company issued security badge. 
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Photo 1. Google Earth overhead image of facility and parking lot in which the incident occurred. Incident location and location of the turnstiles

are noted in the photo. Photo property of Google Earth.
REPORT#: 20KY075 Page 5

Photo 2. Google Earth overhead image of parking lot in which the incident occurred. Photo property of

Google Earth

WEATHER

The temperature was approximately 36°F at the time of the incident. The humidity was 89% with a west wind at 9 mph 

and no precipitation. Weather was not be determined to be a factor in the accident (Weather underground, 2021). 
REPORT#: 20KY075 Page 6

INVESTIGATION

On Friday, December 4, 2020, a 27-year-old male autoclave operator (victim) arrived for his shift at an automotive glass 

manufacturing facility at 6:30 pm. The victim and his domestic partner both worked second shift - a 12-hour shift that 

starts at 6:30 pm and concludes at 6:30 am. According to a site contact, a dispute had ensued between the two earlier 

that day. While specific comments from the victim were not provided, the site contact stated that several other 

employees were well aware of the dispute, as the victim made no effort to hide or conceal his level of unhappiness with 

the current state of the relationship. At approximately 1:40 AM, on Saturday, December 5, 2020, the victim left his work 

station, clocked out and exited the factory four hours and fifty minutes prior to the end of his shift. The supervisor was 

aware the victim had abandoned his station; however, he made no attempt to check up on the victim. Walking off the 

shift is considered a serious offense by the company, and in addition to the employee’s past attendance issues, the

supervisor intended to terminate the victim’s employment. After exiting the building, the victim proceeded through the

gates and into his personal vehicle, which was located in the facility’s parking lot. The victim relocated his vehicle from 

where he had originally parked, near the southeast corner of the parking lot, to a parking spot closer to the entry 

turnstiles, located at the northeast corner of the parking lot. After parking, the victim remained in his vehicle for nearly 

an hour before placing a phone call to his mother at 2:30 am. The call was unanswered and the victim left a voicemail. 

Sometime after placing the call, the victim then died by suicide using a gun.

After she completed her shift at 6:30 am, the victim’s partner exited the facility and entered the parking lot to return to

her vehicle when she located the victim’s car and found his body inside. Upon the discovery, local police and company

personnel were notified. Although the exact time of death is not known, it is estimated to have occurred within minutes 

of placing the phone call to his mother. 

CAUSE OF DEATH

According to the death certificate, the cause of death was a self-inflicted, single penetrating contact gunshot wound of 

the head. 

CONTRIBUTING FACTORS

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger 

sequence of events that ultimately result in the injury or fatality. Kentucky FACE investigators identified the following 

unrecognized hazards as key contributing factors in this incident: 

• Domestic dispute

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should consider providing suicide prevention training to all employees. 

Discussion: According to the U.S. Bureau of Labor Statistics (BLS), suicide in the workplace is on the rise even as the 

overall number of workplace fatalities have steadily declined. Of the 5,333 total occupational fatalities that occurred in 

2019, 307 were workplace suicides - nearly six percent of the total workplace fatalities that year. As workplace suicides 

become more common, employers should consider training employees on the common behaviors associated with 

potential self-harm. According to the American Foundation for Suicide Prevention (AFSP), suicide warning signs can be 

broken into three categories which include talk, behavior and mood. 
REPORT#: 20KY075 Page 7

Warning Signs: Talk

If a person talks about:

• Killing themselves

• Feeling hopeless

• Having no reason to live

• Being a burden to others

• Feeling trapped

• Unbearable pain

Warning Signs: Behavior

Behavior that may signal risk:

• Increased use of alcohol or

drugs.

• Looking for a way to end

their life, such as searching

online methods

• Withdrawing from

activities

• Isolating from family and

friends

• Sleeping too much or too

little

• Visiting or calling people to

say goodbye

• Giving away possessions

• Aggression

• Fatigue

Warning Signs: Mood

People who are considering

suicide often display one or

more of the following moods:

• Depression

• Anxiety

• Loss of interest

• Irritability

• Humiliation

• Shame

• Agitation

• Anger

• Relief

• Sudden Improvement

The AFSP states that there is no single cause for suicide, but it most often occurs when stressors and health issues

converge to create an experience of hopelessness and despair (American Foundation for Suicide Prevention, 2021).

Depression is the most common health condition associated with suicide, but other mental health disorders, substance

abuse, chronic pain, and other health conditions can be also be contributing factors. Employers can access a wealth of

free training information from suicide prevention organizations such as AFSP or develop their own to educate

employees on the signs of suicide. Providing employees with training may equip them with the knowledge to recognize

the signs, take action, and prevent the suicide in the workplace.

Recommendation #2: Employers should implement a system for reaching out to individuals who exhibit signs of

distress, including suicidal ideation.

Discussion: Once suicide prevention training is implemented, employees need a system for reporting persons who

exhibit signs of distress, including suicidal ideation. For most organizations, there is no “out-of-the-box” solution for

reporting coworkers who is thought to be suicidal, but the process should ultimately lead to the company’s human

resources department and if warranted, a mental health professional. It should be noted that not all persons who

exhibit suicidal signs are actually contemplating suicide; however, this determination must be made by a qualified

mental health professional, supporting the need for a system of identifying and reaching out to employees who are

potentially in distress. According to Ellyson Stout, Director of Suicide Prevention Resource Center, “The big thing is, if
REPORT#: 20KY075 Page 8

you feel concerned about someone and their behavior has changed and you’re seeing some of these things to ask. Don’t

hesitate. Asking simple questions such as, “Are you thinking about ending your life?” and listening without judgment to

what the person is experiencing can make a difference”, she says, adding studies show that asking those questions does

not put the idea into a person’s head. In fact, it’s often a relief to be able to talk about what the person is going through

(Human Resource Executive, 2018). After the employee makes initial contact with the potentially suicidal person, he or

she should notify the human resources department timely, or otherwise follow the organization’s policy, if one has been

established. The human resources department should be equipped to handle such situations and can make

arrangements for the individual to discuss their situation with healthcare professionals, like the National Suicide

Prevention Hotline, specifically trained to do so. Many organizations offer Employee Assistance Programs (EAPs), which

may offer crisis assessment and counseling services to employees on short notice and at minimum, are typically aware

of mental health intervention resources in the community. Multiple suicide prevention organizations offer dial-in

(“hotline”) services in which suicidal persons can talk with trained professionals. HR departments and ideally, first line

supervisors, need to be aware of these services, have the information readily available, and be ready to help the

employee contact the proper organization. Employers should establish a reporting system that works best with their

workforce and ensure employees know what to do should they encounter a person exhibiting signs of suicide.

Recommendation #3: Employers should include mental health screenings during annual wellness checks.

Discussion: According to the Kaiser Family Foundation, 84% of employers with 200 or more workers that offer health

benefits also offer annual wellness screenings to employees at little to no cost; however, mental health screenings are

often excluded from these wellness assessments. According to the National Institute for Mental Health, approximately

18 percent of Americans are diagnosed with a mental disorder in a given year. (NBC news, 2018). In addition, a review

of 27 studies in which psychological autopsy studies of suicide deaths were completed, 87.3% of victims were diagnosed

with a mental disorder prior to their deaths (Arsenault-Lapierre et al.). The statistics overwhelmingly support the need

to include mental health screenings in annual wellness checks, so why do employers choose not to do so? Clinical

psychologist, Dr. Brooke Myers Sorger, states that often times, “it is very difficult for individuals to be forthcoming about

their emotional challenges” (NBC news, 2018). Employers - much like employees - can often avoid these difficult

interactions by ignoring the potential issues, thus excluding the screen from regular wellness checks. Mental health

conditions come in in many forms, with symptoms ranging from mild to moderate and severe. An employer may not be

able to immediately recognize an employee with a mental health condition by the physical signs they exhibit; an

employee may also not recognize that his or her difficulties are symptoms of a mental health condition. To help identify

and treat mental health conditions as early as possible, employers should include mental health screenings during their

annual wellness checks. Along with the screening, employers must have a process for making referrals to an EAP or

other qualified healthcare professional (or provide information for self-referral), for those employees who screen

positive for a possible mental health condition.

Recommendation #4: Employers should promote and ensure mental health services are readily available for

employees, including those who may be exhibiting behaviors associated with self-harm.

Discussion: Providing employees with a comprehensive benefits package which encompasses mental health service and

suicide prevention resources is extremely important in today’s workplace. Once those resources are available,

employers should promote the services to verify employees are aware of what resources are available to them. The

promotion of these resources should take place multiple times throughout the year, not just at open enrollment.

According to an article by Forbes, up to 80% of companies reported that their employees do not open or read benefit

materials. Some of the top reasons stated are benefits are complicated and employees are overwhelmed with benefit
REPORT#: 20KY075 Page 9

tools and resources, so they do nothing (Forbes, 2019). Employers may choose to utilize flyers, handouts or training

sessions as a reminder of the resources. Often times, individuals who are contemplating self-harm feel as they are

trapped, with nobody to turn to. Promoting services will keep employees in the know, aware of their options and

increase the likelihood an individual will utilize professional help.

Recommendation #5: Employers should consider providing resources for immediate and long-term suicide

postvention.

Discussion: The effects of suicide are often wide-spread, leaving a lasting impact on those who were engaged in either a

personal professional relationship with the person who died. The Suicide Prevention Resource Center states that an

estimated 115 people are exposed to each suicide that occurs, with 1 in 5 reporting that the experience had a

devastating impact or cause a major life disruption. Exposure to suicide can lead to an array of negative outcomes, some

of which can include mental health issue, social isolation, and an increased risk of suicide. Postvention is an organized

response in the aftermath of a suicide to accomplish any one or more of the following:

• To facilitate the healing of individuals from the grief and distress of suicide loss

• To mitigate other negative effects of exposure to suicide

• To prevent suicide among people who are at high risk after exposure to suicide (Suicide Prevention Resource Center,

2021).

According to the Suicide Loss Task Force of the National Action Alliance for Suicide Prevention, the Key principals for

creating a comprehensive postvention effort include:

• Planning ahead to address individuals and community needs

• Providing immediate and long-term support

• Tailoring responses and services to the unique needs of suicide loss survivors

• Involving survivors ofsuicide loss in planning and implementing postvention plans (Survivors of Suicide Loss Task

Force, National Action Alliance for Suicide Prevention, 2015).

To help employees better face the negative ripple effects of suicide in the workplace, employers should consider

providing resources for immediate and long-term suicide postvention.

Recommendation #6: Employers should consider shift separation for employees who are engaged in a domestic

partnership.

Discussion: According to a company representative, the persons who died was engaged in what was described as an “onagain off-again” relationship with a co-worker. After arriving at work, the victim had made comments to other

employees that he and his domestic partner had been and were actively engaged in an argument. The company contact

stated that the victim “made no attempt to hide his anger” as it related to the dispute between the two. The persons

who died and his domestic partner both worked third shift at the involved business, from 6:30 PM to 6:30 AM. As a best

practice, employers should consider shift separation for employees who are engaged in a domestic partnership.
REPORT#: 20KY075 Page 10

PROGRAM FUNDING

The Kentucky Fatality Assessment & Control Evaluation Program (FACE) is funded by grant 5U600H008483-16 from the 

National Institute for Occupational Safety and Health (NIOSH). 

REFERENCES

Historical Weather Data. Retrieved February 5, 2021 from 

https://www.wunderground.com/history/daily/KPAH/date/2020-8-18

Suicide in the Workplace. Retrieved May 4, 2021 from 

https://www.bls.gov/charts/census-of-fatal-occupational-injuries/fatal-occupational-injuries-by-eventdrilldown.htm

Risk Factors and Warning Signs, American Foundation for Suicide Prevention. Retrieved on February 8, 2021 from 

https://afsp.org/risk-factors-and-warning-signs

Starner, T. (2018, June 21) Suicide in the Workplace: How HR Can Help. Retrieved on February 8, 2021 from 

https://hrexecutive.com/suicide-and-the-workplace-how-hr-can-help/

Trends in Workplace Wellness Programs and Evolving Federal Standards, Kaiser Family Foundation, Retrieved on May 

20, 2020 from https://www.kff.org/private-insurance/issue-brief/trends-in-workplace-wellness-programs-and-evolvingfederal-standards/#:~:text=In%202019%2C%2084%25%20of%20large,do%20health%20screening%2C%20meaning%20in

Arsenault-Lapierre, G., Kim, C., & Turecki, G. (2004). Psychiatric diagnoses in 3275 suicides: a meta-analysis. BMC

psychiatry, 4, 37. https://doi.org/10.1186/1471-244X-4-37

Why don’t Americans get regular mental health checkups? It’s complicated. NBCnews.com. Retrieved on May 10, 2021

from https://www.nbcnews.com/better/health/why-aren-t-mental-health-screenings-part-our-annual-physicalsncna839226

Suicide Prevention Resources Center, Provide for Immediate and Long-Term Postvention. Retrieved on May 20, 2021

from https://sprc.org/comprehensive-approach/postvention

Survivors of Suicide Loss Task Force, National Action Alliance for Suicide Prevention, Responding to Greif, Trauma, and

Distress After a Suicide: U.S. National Guidelines. Retrieved on May 20, 2021 from

https://sprc.org/sites/default/files/migrate/library/RespondingAfterSuicideNationalGuidelines.pdf

Renz, C. (2019, July 2) Only Half of Employees Understand Their Benefits. Here’s What HR Leaders Can Do About It.

Retrieved on February 8, 2021 from https://www.forbes.com/sites/forbeshumanresourcescouncil/2019/07/02/onlyhalf-of-employees-understand-their-benefits-heres-what-hr-leaders-can-do-about-it/?sh=747f14817813
REPORT#: 20KY075 Page 11

INVESTIGATOR INFORMATION

This investigation was conducted by Beau Mosley, Fatality Investigator, Fatality Assessment and Control Evaluation, 

Kentucky Injury Prevention and Research Center, University of Kentucky, College of Public Health. 

ACKNOWLEDGEMENTS

The Kentucky FACE Program would like to thank the involved company for their assistance with completion of this 

report.