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By-the-Book vs In-the-Field: Bridging the Gap Between Policy and Practice Fatality File

Federal safety investigators find Alabama paper mill willfully bypassed safety regulations, leading to fatal electrocution of 36-year-old worker

What Happened

On September 28, 2022, a 36-year-old worker at South Coast Paper LLC in Maplesville, Alabama was fatally electrocuted while performing maintenance on a sheeter machine — a system of six interconnected machines that converts paper rolls into copier paper. When the crew noticed a conveyor belt had stopped, they began replacing the belt's motor without first de-energizing the machines. A hot wire made contact with the ground, energizing the metal conveyor system. The worker grabbed a metal rail and was electrocuted. He did not survive.

What Went Wrong

OSHA's investigation found that the company willfully failed to ensure that hazardous energy control procedures were developed, documented, and followed before maintenance began. Workers were also performing maintenance on machines without the required training. The written lockout/tagout procedure — the policy that existed to prevent exactly this event — was not followed. OSHA issued one willful and one repeat citation, with proposed penalties totaling $295,506.

The Bottom Line

"South Coast Paper's failure to follow established safety procedures cost this worker their life," said OSHA Area Director Jose Gonzalez. The procedure that could have saved this worker's life was already written. It was already required. It simply was not applied in the field on the day it mattered most. The gap between policy and practice is not a paperwork problem — it is a life-or-death gap that supervisors and workers must close on every shift, on every task.

Source: https://www.osha.gov/