Abstract: At approximately 4:30 p.m. on July 19, 2000, Employee #1 was repairing or resetting two chains that had come off their sprockets underneath the #3 garnett line. He crawled under the line into a 2 ft tall by 5 ft wide space with teethed rollers above him and a 6 in. diameter auger rotating at 1,160 rpm. While Employee #1 was under the line, the coworker foreman turned on the doffer roller switch. After crawling past the spinning auger, Employee #1's flannel shirt collar became snagged by one of the doffer rollers. He raised up his right arm reflexively, and it became caught between two teethed rollers. His right arm was mangled in the nip point between the rollers and had to be surgically amputated above the elbow. The motors controlling the doffer rollers had been turned off, but the machine was not locked out or tagged out.