Abstract: At 8:19 a.m. on April 6, 2020, an employee was working as a production operator for a firm that manufactured fabricated pipe and pipe fittings. He was operating an ACRA 36200SET precision gap bed manual engine lathe to trim rubber from a mandrel (pipe) reflex HP oil swell packer. The facility had two ACRA 36200SET manual lathes. The incident lathe had serial number 21367. Employees on two shifts operated the lathes. The pipe being machined in this incident was approximately 15 feet (4.6 meters) long, with an outside diameter (OD) of 6.625 in. (168.275 mm). The rubber was 48 in. (1.22 meters) long, with an OD of 7.5 +/- 0.5 in. (190.5 +/- 12.7 mm). The lathe was turning at approximately 230 rpm. To trim rubber from mandrels, employees mounted the mandrels (pipes) on the lathe and worked according to a written procedure approved in 2014. In one step, employees held a utility knife to trim rubber from the rotating pipe, with their hands within 1 to 2 in. (25 to 50 mm) of the rotating pipe. When blemishes were spotted, strips of sandpaper of different lengths were wrapped around the rotating pipe to smooth out the blemishes. In this incident, the employee was at the finishing stage of the process, cleaning the end of the rubber coating. He was pressing a strip of sandpaper against the mandrel as it rotated. He was caught and pulled in. The employee was carried around the pipe and thrown to the floor. He suffered a laceration to his head, a punctured liver, fractured ribs, and a fractured small finger. He was hospitalized. The lead production operator later said that the use of a utility knife and sandpaper was a common practice. He had trained employees to remove blemishes with strips of sandpaper. He had had a near miss while using sandpaper about a year earlier. He was wearing gloves and sanding with the pipe rotating toward him. The corrective action taken by management was for employees not to wear gloves and to ensure the pipe was rotating away from the operator.