Abstract: On December 5, 2007, A TD-12 Rewinding Slitter was being used to slit and rewind a 4,000 pound roll of specialty paper onto 3-separate rolls. The operator had the rider roll in the lowering position creating pneumatic pressure to press the roll down as the rewinder was rotating to fill the rolls. As the paper increased on the roll the pressure became greater against the down pressure of the rider roll. The pressure became too great and the two locking lugs holding the rewind roll popped loose allowing the three rolls, 2-weighing approximately 1,500 pounds and one approximately 1,000 pounds, to roll out the front of the machine. The guard, designed to hold and prevent the rolls from rolling out, were not in place allowing the rolls to roll out to the floor 4.5 ft below. Employee #1 was in front of the machine on his hands and knees. He was struck in the head and shoulders and crushed beneath 2 rolls of paper. Employee #1 was killed.