Abstract: At 7:30 a.m. on November 4, 2020, an employee was working for a firm that made corrugated and solid fiber boxes. She and her coworkers were cleaning a model 558 pad gluer laminating machine after a production order had finished. The machine had been constructed in the 1960s, and no manufacturer information was available. It was used on an as needed basis: about two hours on November 3, one hour on November 4, and before that, not in the last two months. The workers drained glue from the machine basin and washed down the rollers with a hose. A cover was removed to access the glue basin, but there were no guards to prevent access to the ingoing nip point of the laminating rollers. The rollers were set to the thickness of the cardboard stock being processed, 3/16 in. (0.1875 in. or 4.76 mm). The top compression roller was rubber coated, while the lower glue roller was metal covered. The rollers were 30 in. (0.76 m) long and 8 in. (203 mm) in diameter. The machine was connected to its power source via a cord and plug. It was not unplugged for the cleaning. The rollers were turning. A coworker cleaned the glue rollers on the outgoing side, while the employee cleaned the rollers on the ingoing side. Both were using handheld sponges to wipe glue from the still-turning rollers. The employee's right arm was pulled between the glue and compression rollers. A coworker pressed the machine's emergency stop button above the compression rollers. The employee had to be extracted from the machine. She was hospitalized with severe arm injuries. The firm had not developed or implemented any written or verbal procedure to isolate energy. Only the machine operators (men) received LOTO training. The employee had used rags to clean the rollers in the past. The rags kept getting caught, so she had switched to sponges. No hand tools other than sponges were provided for working on the machine. The plant supervisor was in the production area daily. The unguarded rollers were plainly visible.