The night shift crew at a paper mill told the incoming day shift supervisor that the press was putting an unwanted black line on the paper being produced.

The machine tender attempted to remove the cause of the line by sanding the outgoing roll with emery paper, but it wasn’t working.

The day shift supervisor reached into the incoming side of the press with his left arm to try sanding the paper roll. His arm was just one inch (2.54 centimeters) from the felt carrying the paper onto the rolls and only eight inches (20.3 cm) from the nip point where the rolls met.

Suddenly his left hand was caught and pulled through the nip point. His arm was crushed and nearly cut off just below the elbow by the steel frames of the two rolls. A tourniquet was applied to his arm to control bleeding, and he was taken to a hospital. His arm had to be amputated just below the elbow. Eleven days after the incident he died when a blood clot reached his lungs.

Why did this supervisor take such a risk? Never let distraction or production pressure prevent you from working safely.