Abstract: A disc and roll machine, designed by its manufacturer to perform operations on small sections of spiral wound paper tubing, had been in operation for over 10 years. During this time the type of tubing used in the machine was changed from paper to plastic. The machine consisted of a nine-mandrel head that rotated on a horizontal axis with an adjustable-stroke horizontal push rod opposite each mandrel. About three to four months before the accident, the machine was set up to process plastic sleeves for D batteries. Precut sleeves were fed via the feed chute into the machine, where a push rod shoved the tube partway onto a mandrel. It then rotated past a heater and one end of the tube shrinks around the mandrel end, forming an inside flange. The mandrel head advanced two times per minute. When set up for paper tubes, the machine was fed automatically by filling a feed bowl and included an automatic shutoff in case of a misfeed or if the feed mandrel was left bare for any reason. A sliding perforated metal guard was used to bar access to the general point of operation. With the plastic sleeve setup neither the feed bowl nor the automatic shutoff feature could be used; instead, an inclined feed chute had been installed that requires feeding by hand. This feed chute required removal of the guard. It was believed that the 12- to 15-in. distance between the feed point and the point of operation, and the interferences between these two points, coupled with the fact that access to the point of operation should not be needed without shutting down the system, made a guard unnecessary. Training was usually done either because the trainee had not worked with the machine at all or because it had been a while since it was last operated. It was customary to pair an experienced operator with a trainee until both felt that the trainee was able to work alone. During Christmas week of 1984, the regular supervisor was on vacation and his job was covered by a supervisor of related departments. They often covered for each other, since their departments were interrelated. Apparently, a machine operator without experience on the machine was assigned to operate it. She cut one or more of her fingers and was hospitalized for her injury.