Abstract: On September 5, 2008, Employee #1, a printer with Print Connection, was cleaning a roller on printing machine with a rag in his right hand when his index finger became pinched between the roller and a metal tray. He was hospitalized at Western Hand Center for an amputation. The machine power was on and the roller was running when the incident occurred. When interviewed, Employee #1 indicated that he had been trained in lockout/tagout safety rules by his employer but forgot to turn off the power prior to the cleaning work. There was no guard at the pinch point between the roller and the metal tray at the time of the incident, but one was installed subsequently.