Abstract: At 6:30 a.m. on April 16, 2021, an employee was working for a firm that manufactured corrugated and solid fiber boxes. He was operating a Marquip Model III L Sheet Runner dual rotary precision sheeter. This machine had slitter blades that cut off excess paper when a roll of paper was wider than needed for a scheduled job. Occasionally, cut-off excess paper did not feed smoothly off the roll and bunched up. Employees would then reach into the running machine, within 5 in. (127 mm) of a slitter blade, to redirect the cut-off paper into the waste area. Although employees stated that they slowed the machine down prior to performing this task, their hands were near the rotating slitter blades. The slitter blades could be adjusted to various positions, depending on the width of the paper to be cut off from the roll. The blades were 12 in. (305 mm) from the top of the guard rail. In this incident, the employee had been clearing and redirecting the cut-off excess paper coming off the machine while the machine was running. He reached in with his right hand to remove paper. The employee had slowed the machine down before reaching in, but one of his fingers was pulled into the path of the slitter blade. The tip of the finger contacted the trim blade, and the employee suffered the amputation of the fingertip before the first knuckle. He was hospitalized. During an interview, the facility's environmental, health, and safety manager said that the sheeter was operated 24 hours a day, 7 days a week, but that the slitter was not always used. Sheeter jobs that required the use of the slitter occurred only two to four times per month, with each job lasting between 12 and 36 hours, depending on the size of the order. The sheeter had been in the facility since 2005, and the bunching problem had occurred for as long as the machine had been in use. Though trained to turn the machine off first, employees said that they normally corrected the bunching while the machine was running.