INCIDENT HIGHLIGHTS 

REPORT#: 22CA001 REPORT DATE: March 24, 2023

Forklift Operator Dies After Falling Into a

Recycling Baler — California 

DATE: 

September 2, 2022

TIME: 

6:05 a.m. 

VICTIM:

58-year-old male forklift 

operator 

INDUSTRY/NAICS CODE:

Manufacturing, Pulp & 

Paper/32 

EMPLOYER: 

Manufacturer of paper 

products 

SAFETY & TRAINING:

The employer had a safety 

program, but not all 

employees completed their 

training 

SCENE: 

Warehouse where paper 

products are manufactured 

LOCATION:

California 

EVENT TYPE: 

Crushed by

SUMMARY 

On September 2, 2022, at the end of the night shift, a 58-year-old 

forklift operator was delivering waste into a recycling baler. He 

climbed down from the forklift while it was still running, and left the 

forks in a raised position. Although this was an unwitnessed incident, 

video from a nearby security camera showed him climbing the stairs 

to the recycling baler control panel. When he didn’t answer his radio 

or return the forklift at the end of his shift, co-workers began a search 

for him. He was found inside the recycling baler crushed to 

death...READ THE FULL REPORT> (p.3)

CONTRIBUTING FACTORS 

• Inadequate communication between forklift operator and 

supervisor 

• Inadequate/incomplete training on recycling baler operation

...LEARN MORE> (p.7)

RECOMMENDATIONS

California FACE (CA/FACE) investigators concluded that, to help 

prevent similar occurrences, employers using recycling equipment 

should: 

• Ensure that all personnel who operate balers are fully trained and 

supervised on procedures to remove a jam properly. 

In addition, recycling baler manufacturers should: 

• Design and install safety features to keep workers away from 

moving parts...LEARN MORE> (p.7) 
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 California Fatality Assessment and Control Evaluation (CA/FACE) 

Program. CA/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 CA/FACE program is located in the Occupational 

Health Branch, California Department of Public Health. 

Email | Website

Page 2 
INTRODUCTION

On Friday, September 2, 2022, at approximately 6:13 a.m., a 58-year-old male forklift operator suffered 

fatal injuries when he was crushed inside a recycling baler. The CA/FACE investigator received 

notification of this incident on September 19, 2022, from the weekly summary from the California 

Department of Industrial Relations, Public Information Office. Contact with the employer was made by the 

CA/FACE investigator on October 17, 2022. A site inspection and an interview with the human resources 

manager was conducted on October 20, 2022. The police report, with co-worker statements, was 

received and reviewed. 

EMPLOYER 

The employer was a paper manufacturing company that produced premium quality paper products including 

paper towels, toilet paper, and facial tissue. The company moved to their current location in 2019 and had 185 

employees at this facility. There were approximately 40 workers on the night shift at the time of the incident, 

including five forklift operators who provided service to the production line. 

WRITTEN SAFETY PROGRAMS and TRAINING 

The company had a written Injury and Illness Prevention Program (IIPP) with all the required elements 

such as lockout/tagout, machine operation, and forklift training. Training was accomplished mostly 

through online training programs prepared by the employer, and on-the-job training (OJT) by coworkers. According to the employer’s human resources manager, the victim was in the process of being 

trained on how to operate the recycling baler. 

WORKER INFORMATION 

The victim was a 58-year-old male forklift operator who had been employed by the company for ten weeks 

before the incident occurred. His typical job duties included delivering raw material to the production line, 

bringing finished paper products to the shipping and storage areas, and dumping waste products from 

the production line into the recycling baler.

EQUIPMENT 

The equipment involved in this incident was a horizontal type, closed door, two-ram industrial recycling baler. 

This particular machine was purchased as a prototype under development from the manufacturer. It was an 

automatic baler that did not require an operator for compacting and baling material. After the forklift dumps 

bulk material into the baler input hopper (Exhibit 1), a photo-eye sensor automatically triggers the 

compression ram when the baler input area is full. The hydraulic ram engages to compress the material until 

the ‘bale full’ light is illuminated, and the bale is tied off and ejected. The material is then automatically bound 

using wire, and a single ram pushes the finished bale out of the machine (Exhibit 2 & 3). 

REPORT#: 22CA001 Page 3 
Exhibit 1. The recycling baler with input hopper. Photo by CA/FACE program.

Input hopper

 Exhibit 2. The location where the finished bale is expelled. 

 Photo by CA/FACE program.

REPORT#: 22CA001 Page 4
Compression

Ram

Exhibit 3. The single hydraulic compression ram that pushes the 

 finished bale out of the machine. Photo by CA/FACE program. 

When material becomes jammed in the baler input, either in the compression or output areas, the operator 

should turn the key switch on the control panel to the off position and push the emergency stop button 

(Exhibit 4). The operator should then notify the supervisor using the company issued radio which is carried by 

all operators. A lockout/tagout procedure is then implemented prior to entering the baler areas. 

Exhibit 4. The recycling baler control panel with emergency stop button. 

Photo by CA/FACE program.

Key switch Emergency 

stop button

REPORT#: 22CA001 Page 5
INCIDENT SCENE 

The incident scene was a large 800,000 square foot warehouse that manufactured kitchen, bath, and 

facial tissue. The facility had one recycling baler that was located in the raw material storage area within 

the warehouse. 

WEATHER 

The weather was not a contributing factor in this incident since it occurred inside the facility. 

INVESTIGATION 

On the day of the incident, the victim worked the night shift, which started at 10:00 p.m. and ended at 

6:00 a.m. In addition to the victim, there were two other forklift operators working that night. At the 

beginning of the shift, the forklift operators met with their supervisor to get their assignments and 

radios. Their job duties that night included delivering raw material to the production line, bringing 

finished paper products to the shipping and storage areas, and dumping waste products from the 

production line into the recycling baler. The recycling baler was set to the automatic cycle, so forklift 

operators did not need to access the control panel to make a bale. 

At approximately 6:00 a.m., one of the day shift employees noticed that the victim had not returned with 

the forklift. He notified his supervisor, who then tried to reach the victim on the radio, but he did not 

respond. A co-worker searched the area where the recycling baler was located and observed the victim’s 

forklift next to the hopper with a bin loaded on the forks. When the co-worker was not able to locate the 

victim, he notified the supervisor. The supervisor arrived at the baler and turned the key switch on the 

control panel to the off position. A second co-worker opened the compactor’s side compartment and 

observed blood on multiple pieces of cardboard, and the victim’s body inside. Emergency services were 

called at 6:32 a.m. Police, fire, and paramedics arrived at 6:41 and secured the incident scene. The 

coroner declared the victim dead at the scene. After the incident, review of the security video camera 

showed the victim climbing the stairs to the control panel (Exhibit 5), but stacked material blocked the 

view of his subsequent activities. 

REPORT#: 22CA001 Page 6
Exhibit 5. The stairs leading to the control panel. Photo by CA/FACE program. 

CAUSE OF DEATH 

The county coroner listed the cause of death as multiple blunt force injuries. 

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. CA/FACE investigators identified the 

following unrecognized hazards as key contributing factors in this incident: 

• Inadequate/incomplete training on recycling baler operation 

• Inadequate communication between forklift operator and supervisor 

RECOMMENDATIONS/DISCUSSION 

CA/FACE investigators concluded that, to help prevent similar occurrences, employers using recycling balers 

should: 

Recommendation #1: Ensure that all personnel who operate balers are fully trained and supervised on 

procedures to remove a jam properly. 

Discussion: In the incident, it is not known if the victim slipped from the platform or climbed into the hopper 

to remove the jam, i.e., attempting to remove material that was jammed inside the baler. The supervisor 

stated that the machine was running at the time of the incident, suggesting that the victim did not turn the 

machine off when he was at the control panel. Logout/tagout was not performed. 

REPORT#: 22CA001 Page 7
In this facility, forklift operators were allowed to turn the baler on and off in the event of a machine 

malfunction. The appropriate procedure was to turn baler off at the control panel and notify a supervisor, who 

in turn may call maintenance to perform logout/tagout. It is unknown if the victim tried to remove jammed 

material in the past, or if he was fully familiar with the operation of the baler and safety procedures. It is 

possible that the victim may not have been aware of the possibility of machine activation by the photo-eye 

sensor. If the victim had been fully trained on proper procedures, he may not have attempted to correct the 

machine malfunction himself. 

In addition, manufacturers should: 

Recommendation #2: Design and install safety features to keep workers away from moving parts. 

Discussion: In this incident, the victim was able to gain access to moving parts of the recycling baler while it 

was in operation. The design of the bale hopper had physical barriers (yellow), but they did not prevent access 

to moving parts (Exhibit 6). Collaboration between employers and machine manufacturers may result in 

additional safety devices that could be added to the machine to ensure worker safety when working in close 

proximity to moving parts. 

Hopper Red cable

Safety 

barrier 

 Exhibit 6. The yellow barrier around the control panel to prevent access to the hopper. 

The red cable was added after the incident occurred. Photo by CA/FACE program. 

DISCLAIMER 

Mention of any company or product does not constitute endorsement by CA/FACE and the National Institute for 

Occupational Safety and Health (NIOSH). In addition, citations to websites external to CA/FACE and NIOSH do not 

constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, CA/FACE 

REPORT#: 22CA001 Page 8 
and NIOSH are not responsible for the content of these websites. All web addresses referenced in this document were 

accessible as of the publication date. 

REFERENCES 

Division of Occupational Safety and Health - Title 8 regulations - Subchapter 7 - General Industry Safety 

Orders, Group 8. Points of Operation and Other Hazardous Parts of Machinery - Article 61. Compaction 

Equipment ◦§4350. Scope.

◦§4351. Definitions. 

◦§4353. Stationary Compaction Equipment and Balers. 

◦§4355. Operating Rules for Compaction Equipment. 

Group 6. Power Transmission Equipment, Prime Movers, Machines and Machine Parts - Article 41. Prime 

Movers and Machinery ◦§4002. Moving Parts of Machinery or Equipment. 

Group 2. Safe Practices and Personal Protection - Article 7. Miscellaneous Safe Practices ◦§3314. The Control 

of Hazardous Energy for the Cleaning, Repairing, Servicing, Setting-Up, and Adjusting Operations of Prime 

Movers, Machinery and Equipment, Including Lockout/Tagout. 

Cal/OSHA - Title 8 regulations 

Chapter 4. Division of Industrial Safety 

Subchapter 7. General Industry Safety Orders 

Group 1. General Physical Conditions and Structures Orders 

§3203. Injury and Illness Prevention Program. 

Subchapter 4. Construction Safety Orders 

Article 3. General 

§1509. Injury and Illness Prevention Program. 

California FACE Report #05CA003 (PDF)

California FACE Report #09CA005 (PDF)

California FACE Report #09CA009 (PDF)

NIOSH Publication No. 2003-124: Preventing Deaths and Injuries While Compacting or Baling Refuse 

Material (PDF)

REPORT#: 22CA001 Page 9 
NIOSH Safety and Health Topic Page on Machine Safety

INVESTIGATOR INFORMATION 

This investigation was conducted and authored by Hank Cierpich, Fatality Investigator/Consultant. Additional 

contributions to the report were provided by Robert Harrison, MD, MPH, CDPH FACE Project Officer; Laura Styles, MPH, 

FACE Research Scientist; and Glenn Shor, PhD, Cal/OSHA CFOI Program. 

REPORT#: 22CA001 Page 10