Abstract: When press rollers are changed, they are held in place by slip rings secured by Allen-type set screws. Employee #1 had ceased to use the Allen wrench for some reason, and had started using a long set screw that was turned in with a pair of pliers. This set screw protruded from the shaft about 1/2 in. and the shaft holding the roller protruded over a maintenance walkway. The walkway is about 1 ft above the floor and the shaft is about 5 ft above the walkway. This brings the shaft end within 7 ft of the floor. Employee #1 decided to paint the press without stopping it. As he was on the walkway painting, he backed into the protruding shaft and the set screw caught the right shoulder of his overalls. His clothing began to wind up on the shaft and Employee #1 was pulled up and over the shaft at least twice. The strain caused his clothes to rip and they were pulled from his body. Before he could hit the stop button, which was close at hand, his left thumb became caught between his shirt sleeve and the roller. The effort to extricate himself and the pressure applied from the roller caused his thumb to separate between the first and second knuckle, removing that portion of his thumb along with the bone, a segment of tendon, and blood vessels. The trauma to the separated portion was sufficient to render it unsalvageable.