Abstract: Around 5:20 p.m. on September 4, 1999, Employee #1, a packer, suffered a right middle fingertip amputation while attempting to clean printer rollers during operation. The facility involved in the accident was a large polyethylene bag manufacturing company. Employee #1 had been working there one and a half years, as a packer. At the time of the accident she noticed ink smears on the product, and, although formally instructed not to perform any operator's duties, took it upon herself to clean the rollers. No operator was in sight, and Employee #1 had previously been reprimanded for not taking action to correct a similar problem. Because she had not been given training on proper clean-up procedures, she used a rag to wipe off a ball of ink; the in-running rollers pulled the rag, and Employee #1's finger, into the nip point. Employee #1 was transported, by the supervisor, to Lemus Medical Center, and then had surgery at Western Hand Specialists. Interviews were conducted with Employee #1, another packer, and one machine operator. There were no witnesses to the accident.