Abstract: On November 8, 1991, Employee #1, of D. L. Carpenter--Mechanical Contractor, was sent to Newark Pacific paper mill to work. Once at the work site, Employee #1 was instructed to install a metal plate on the vat housing next to cylinder #1 in the wet end area. The cylinder was operating 5 to 6 in. from the point of installation. At 9:15 a.m., while Employee #1 attempted to place the plate into position, it struck the cylinder's inner spokes. The plate was knocked from Employee #1's hands and his left little finger was severed. Employee #1 was transported to a hospital, where his finger was reconstructed. No lockout/blockout procedures were implemented.