Abstract: On August 17, 1995, Employee #1, a laborer for an insulation contractor at a large metropolitan refinery, was in the fabrication area waiting to receive materials for delivery to the work area. He decided to reroll a piece of sheet aluminum to the proper radius using a 0.5 HP, foot-activated metal roller. While preparing to run the metal through the unit, he accidentally pressed the covered foot pedal. Two fingers on his right hand were caught by the in-running rolls, which had a pinch point of 7 3/4 in. from the face plates. The distal phalanx of his index finger was amputated, and his middle finger was bruised. Employee #1 was taken to Long Beach Memorial Medical Center, where he was treated and released five hours later. The insulation contractor had acquired the roller second hand, and it had no name plates. The face plate had 1 and 3 1/2 in. gaps. The larger gap may have been intended as a viewing window, but there was no indication that any transparent cover had ever placed over the opening.