Abstract: Employee #1 and coworkers were working on the calender press of a 30-year-old, custom-made paster machine designed to merge together two sheets of cotton fiber paper by passing them through a series of calender rolls. The first set of calender rolls applied polyvinyl alcohol paste between the sheets of paper; the second set pressed the two sheets together to form a strong cotton paper that was used for electrical insulation. According to the machine operator and previous helpers, Employee #1's job was to stand at the back of the press calender, at the out-going nip point, and take hold of the paper as the machine operator passed it through the press rolls. This occurred while the calender rolls were in the open position and the machine was in jog mode. Employee #1 was then to wrap the paper around a take-up roll while the operator put the machine in regular cycle. After about 15 minutes, the take-up roll would be full. The operator would stop the machine, and Employee #1 would wrap the paper roll in brown paper, tape it, and put it on a pallet. The next sheets of paper were then threaded through and the process was started again. The width of the two sheets of paper was not always equal, creating an overlap edge. When this occurred, the overlap sometimes stuck to the roll and tore when it was just threaded and the machine was still in jog mode. Employee #1 was to tear this off and rip off the edge of the paper so it would wrap smoothly. This sticking/tearing of the paper often left a paste residue next to the width of the paper roll on the rubber calender. It was the operator's job at the end of the day to hose down the calender with hot water to remove it. When Employee #1 first started working at the machine five months before the accident, the operator caught him near the in-running nip side of the press calender. He was trying to scrape away the paste residue from the rubber calender while the machine was in full speed and the calendars were closed, creating a dangerous nip point. The operator told Employee #1 to stop, explained about the dangerous nip point in that area, and clarified that he cleaned away the residue at the end of each day. On the morning of the accident, the operator again caught Employee #1 cleaning while standing at the in-running nip point and warned him of the danger. Employee #1 complained that he disliked the sticky material on the calender. Later that morning, while a roll of paper was processing through the machine at full speed, the machine operator and a coworker heard Employee #1 screaming from the press area at the middle of the machine. The operator pressed the emergency STOP button at the control box as he approached the press area. Another coworker, approaching from the opposite end of the machine, pushed a button to open the calender rolls. Employee #1's fingers were amputated when they passed through the nip point of the calender.