Abstract: On February 13, 2004, Employee #1 was cleaning the top die board of a Midline 924. This machine shapes, cuts, creases, folds, and glues cardboard sheets as they pass through the machine forming them into cardboard boxes. One of the components of this line is a die board cutter, which has two large rolls that sit one on top of the other. The top roll is called the die board roll and the lower one is called the anvil. This die board cutter is responsible for cutting the holes in the cardboard boxes for handling points. To cut through boxes, preshaped knives imbedded on wooden die board and this die board is shaped like a trough and fits snugly on the upper cylindrical Serrapid roll. The die board is held in place on the Serrapid roll by pins, which are positioned at regular intervals on the surface of the roll. These pins are pushed out of the cylinder by air to permit the installation and dismantling of the die board. The anvil holds the cardboard as it is being cut and passes it forward to the end of the line. To clean the top die board, Employee #1 reversed the Serrapid roll by activating a momentary switch. As the Serrapid cylinder was rotating, his left glove got snagged on the knives of the moving die board and was pulled into the in-running nip-point between the two rollers. Employee #1's left index finger was lacerated, and then required surgical amputation three weeks later There were no engineering or administrative controls to address this hazard during cleaning operations.