Abstract: On November 24, 2008, Employee #1 and two other employees were attempting to remove an end cap from a press roll for a paper manufacturer. During the process, they had removed all retaining bolts from the end cap and roll. The employees failed in all attempts to remove the end cap with pusher bolts. In further attempts to remove the end cap, they attached an air valve and pressure gauge to the roll and applied 50 psig (pounds per square inch gauge) to the inside of the roll. The employees left the air pressure in the roll over the weekend. At the start of the new week, employees again attempted to remove the end cap with pusher bolts. When the cap released from the roll, it struck and killed Employee #1.