Abstract: At 1:45 p.m. on November 14, 2019, an employee was working full-time as a machine operator for a company that manufactured tires. He was operating the number 5 sheeter and mill transfer conveyor. The number 5 sheeter mill ran around the clock. The transfer conveyor moved heated rubber from the mill to the sheeting process. The crossover conveyor was 36 in. long and 14 in. wide (0.9 meters long and 0.35 meters wide). It was about head high, or 5 feet (1.5 meters) above the floor in front of the operator. Material was cleaned out of the conveyor about two to three times per shift or per day, during changeovers, during which times the mill was stopped. The mill had a 480-volt electrical disconnect that could be locked out by authorized employees. Machine operators had been trained only as affected employees and were not authorized to perform lockout/tagout. It was common for workers to reach in to clear debris, but only after they had turned off the conveyor by pushing the belly bar and the emergency stop (E-stop). The machine was still energized. Because operators were not authorized to perform LOTO, they were exposed to a caught-in hazard when they cleaned out the conveyor. The conveyor's internal idlers were not guarded. In this incident, the employee saw a small ball of rubber on the transfer conveyor belt. He had cuffed gloves on. With the conveyor still running, he stuck his arm in three times to remove the rubber, uneventfully. The fourth time, his right forearm was caught between the conveyor transfer belt and an idler. The employee hit the belly bar to stop the machine. He was hospitalized to treat a fracture to his forearm. The firm had hired a company a year earlier to advise on LOTO procedures. This transfer conveyor was the only one left in the building. Within the next few years, the process would be updated. The employer installed a guard to cover the transfer conveyor. It was having a machine shop build a guard to completely enclose the entire area.