Abstract: At 5:35 a.m. on October 10, 2020, an employee was working for a commercial bakery. It made baked products for the novelty ice cream industry. The employee was working on the night shift, cleaning machinery. On this night, he had been assigned to clean the rollers on ice cream line 1, which was on the west side of the plant. He was cleaning the rollers on the Thomas L. Green rotary cutter die with serial number 2005 48533 and an additional serial number of RC201 048 2005 2679. He was working near a conveyor that was 31-3/8 in. (31.375 in. or 797 mm) above the floor. He placed his lock on the area where his work colleagues had trained him to place it. The rollers, though, remained energized while he worked. This was as common practice. The rotary die on the cookie line one had no guarding underneath the conveyor. As the employee was cleaning under the rollers, wiping cookie residue from them, the rag he was using was pulled into the rollers. His right arm was pulled into the rollers as well. The employee's right arm was fractured in several places. The employee was hospitalized. The employee had been given lockout/tagout (LOTO) training, but he had not been taught how to follow or utilize LOTO procedures for the rollers on the cookie line.