Abstract: Employee #1, a coater machine operator on the third shift (11:00 p.m.-7:00 a.m.), was instructed by his supervisor to clean the coater machine rollers at the start of his shift. Employee #1 had worked his position for about three months and had been trained on the machine for 1 week by a fellow employee. This was only the third time that he had had to clean the rollers. As instructed, Employee #1 removed the guard, did all set-up procedures, and reduced the roller speed to slow. After washing the rollers off with warm water, he set them so that they were practically touching each other. There are two top rollers and one bottom roller. The top silver roller was 32 1/4 in. long with a diameter of 3 in. The top gray roller was 32 in. long with a 5 in. diameter, and the bottom silver roller was 30 in. long with a 4 in. diameter. Employees had been instructed to keep the top two rollers at least 1 in. apart when wiping them off, Employee #1 went to the rear side of the coater machine and started cleaning the top rollers with a water soaked rag. As he started cleaning the top silver roller with his left hand (Employee #1 is left-handed), his left thumb was somehow pinched between the top silver and gray rollers. He was able to free his thumb from between the rollers. Employee #1 lost the meaty underside part of his left thumb and part of the nail. Union Memorial Hospital was unable to re-attach the amputated sections.