PERRYVILLE, Mo. — In February 2023, an employee for a large food manufacturer was cleaning a machine at a southern Illinois factory when his right hand was sucked in by two metal rollers, crushing three fingers that were later amputated.
Nineteen months later in Perryville, a plant employee for the same company was replacing a splash guard on a rotating cooker when another worker came back from a break and activated the machine. The cooker began rotating, catching the employee’s arm and severing it near his shoulder.
Then, in June this year, at that same Perryville plant, an employee became stuck in one of the factory’s industrial-sized ovens. He was dead by the time first responders could get to him, police said.
The death of Nicolas Lopez Gomez, 38, remains under investigation by the federal Occupational Safety and Health Administration.
But if OSHA finds that the company violated safety requirements also cited in the two previous accidents, it could result in steep fines — and even criminal charges.
The company under the microscope is Gilster-Mary Lee, a large private-label food manufacturer based in Chester, Illinois, just 60 miles south of St. Louis. It employs more than 2,000 and reported $630 million in revenue in 2024, according to the St. Louis Business Journal. It manufactures hundreds of private-label foods and food service products, including cereal, cake mixes, dinner kits and baking products as well as cardboard and other packaging.
Now, a decade of OSHA records reviewed by the Post-Dispatch illustrate a history of safety violations at Gilster plants that have led to serious injuries, including 10 amputations.
In those records, Gilster was repeatedly cited for failing to perform elements of a specific, and key, safety procedure, called a “lockout tagout.” The practice involves an employee first physically locking the valve, switch or other mechanism that turns on a machine, often so the worker can service or clean the equipment. Then the employee tags the lock with a warning label.
In all, the company has been fined about $200,000 in 18 OSHA cases for safety violations at its plants in Missouri, Illinois and Arkansas, not including Lopez Gomez’s death, according to the newspaper’s analysis.
Of those, eight included citations for violating requirements for locking or tagging machinery.
Experts say it signals a more serious problem.
“That kind of recurrence is typically not about individual workers making mistakes,” Dustin Hickey, founder and principal consultant at Alabama-based LegacyMark Safety Consulting, said in an email after reviewing the company’s OSHA record. “Oftentimes, repeat injuries, citations and escalating penalties are not coincidental, but may reflect a company-wide breakdown that puts workers at risk.”
In response to a request for an interview, Gilster President Tom Welge sent the Post-Dispatch a statement saying the company devotes significant time to safety training every year.
“Any on-the-job injury is unacceptable and upsetting to our entire organization because of our diligent efforts to prevent injuries and foster a strong safety culture,” he wrote.
He later added that a 2024 independent focus group of employees identified the company’s focus on safety as one of its strengths.
OSHA violations
Nine Gilster citations over the past decade had to do with “machine guarding,” or the use of physical barriers and other safety devices to prevent worker injuries caused by contact with dangerous parts of machinery. Four of those citations involved accidents that resulted in finger amputations.
One accident produced a citation for not properly covering sprockets and chains with a case.
And, of the eight citations for lockout-tagout procedures, five came during inspections, and three for accidents — all three leading to amputations.
“It definitely stands out,” said Chris Janson, principal at St. Louis-based workplace safety consulting firm Haines, Janson & Associates. “Just because it’s a large company does not mean that you have this frequency of these kinds of significant injuries and alleged OSHA violations.”
In the February 2023 amputation incident, which happened at a factory in Centralia, Illinois, about 70 miles east of St. Louis, OSHA investigators found that the plant’s lockout-tagout procedures did “not affectively address the steps for how to shut down the machine and verify that the machine is deenergized.”
They cited the company for not locking and tagging out as required, and also for not clearly outlining lockout-tagout information, for having procedures that did not identify all energy sources of the plant’s machines and for not testing the machines to verify the effectiveness of its lockout-tagout procedures.
Gilster negotiated with OSHA and landed on a total penalty of $17,411 in that 2023 incident, according to records.
In the September 2024 accident at the Perryville plant in which a worker’s left arm was amputated, Gilster was cited for violating a variety of lockout-tagout procedures.
One of those citations was a repeat violation of the same standard cited in the February 2023 incident — which means OSHA, as a punishment for the repetition, multiplied that citation’s $16,550 penalty by five for a total of $82,750 — for just that violation.
But the company again negotiated the penalty down to $20,000, according to records.
OSHA investigators noted in that report last year that there had been 21 disciplinary actions against the company since February 2019.
‘It’s the scale’
Gilster employees called 911 on the afternoon of June 26 when Lopez Gomez became trapped in an industrial oven at the Perryville cereal plant, at 615 Old St. Marys Road, about 80 miles south of St. Louis. The plant sits just across the street from the company’s cake plant.
Lopez Gomez died by the time emergency workers could get to him. Perry County Coroner Meghan Ellis on Friday said her investigation is closed but the records were not yet available for release.
Christina Allen, who said she worked at a Gilster plant for about two years a decade ago, told the Post-Dispatch in July that the giant oven should have been locked out and tagged. Lopez Gomez’s death, she said, could have been avoided.
Former and current Gilster employees agreed, telling the Post-Dispatch as far as they could tell, the machine was not locked out as Lopez Gomez cleaned the 30-foot oven.
Janson, the safety consultant, said lockout-tagout procedures are key because workers starting equipment are sometimes too far away, physically, to see it actually turn on.
“All this stuff in these big manufacturing plants, some of the controls and some of these manufacturing lines are so long you could be four or five house lengths away from where the equipment is started compared to where the equipment lives,” Janson said. “It’s the scale. There’s the lack of vision to be able to see what’s going on from the person operating the controls to the person who’s out there servicing the equipment.”
At the time of his death, police said Lopez Gomez was a Guatemalan national who was working at the plant under the alias of Edward Avila.
His body was transported back to Guatemala to his parents, employees said. His family could not be reached for comment.
After his death, Homeland Security officers came to the Perryville employment office, said Welge, the company’s president. They asked to review hiring documents, Welge said, and the company cooperated. “There have been no other visits to other facilities, nor do we have any knowledge that any employees were detained,” Welge said.
Still, if investigators cite Gilster for the same lockout-tagout violations in Lopez Gomez’s death as in the previous two amputations, it would be the third such violation in five years.
That would result in OSHA multiplying the fine by 10.
OSHA would then have to determine if the company willfully violated the safety procedure, and if that violation directly resulted in his death.
The final result could be a fine of up to $165,514 per violation.
In addition, the Department of Justice evaluates the incident and decides whether to pursue criminal charges.
Chip Darius, founder and president of Safety Priority Consultants, a Connecticut-based company that specializes in occupational safety and health, said, without specifics, it’s too early to jump to conclusions.
“But there’s certainly a track record of other similar incidents with this company,” he said. “This sounds like a third strike for essentially the same set of lockout-tagout failures under the same corporate umbrella.”
As an example of a willful violation, Darius pointed to the 2012 case against Bumble Bee Foods after an employee died in a pressure cooker that was turned on with him inside the machine because lockout-tagout procedures had not been followed. Federal authorities charged the company, its operations director and its safety manager with violating OSHA rules causing a death.
The company later paid $6 million in a settlement. The two employees pleaded guilty to criminal charges and were fined thousands of dollars, but avoided a possible prison sentence, according to media reports.
But Janson said OSHA findings of willful violation are pretty rare.
“As you move up the food chain in severity with these types of OSHA issues, it becomes very litigious,” he said.
‘Gotta stick together’
Perryville, a small town of 8,500, is home to Gilster’s two plants, an automotive parts factory and a well-kept downtown with local shops and restaurants.
Most intersections feature huge murals painted on the sides of brick buildings, several touting Perryville as a historic destination, and others featuring colorful art of things like flowers and books.
About half a mile away, on a recent rainy afternoon, Gilster employees — some donning hairnets — filtered in and out of the tan, one-story Gilster cereal factory.
Terry Anthony, of Cape Girardeau, said he’s worked at the Gilster plant for about six years and knew Lopez Gomez, whose death still confuses him.
“He was a cool guy,” he said. “To this day I still don’t know what happened.”
Anthony, a plant operator, said safety is a team effort at the plant and is a major focus of his.
“You gotta stick together,” he said before heading back to the plant after his break, “so we can all go home.”
Soon after Anthony disappeared back into the plant, Timothy Riney, of Perryville, was outside throwing away remnants of a McDonald’s lunch.
He told the Post-Dispatch he has worked for Gilster for almost two years as a maintenance employee.
“I lock stuff out all the time,” he said. “They teach us about safety.”
He didn’t know Lopez Gomez but said his death continues to have an impact on employees who were there when he was killed.
“Some of them are still going to counseling,” he said.
One manager, he said, still has nightmares about that day.
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Dana Rieck | Post-Dispatch
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