Abstract: At 9:35 a.m. on November 5, 2019, an employee who worked as a Bottling Manager for a wine bottling operation and storage warehouse was making an adjustment to a sprocket and chain system of an overhead box conveyor. The Bottling Manager ensures the production line runs smoothly. The production line consists of machines and conveyors link together from one side of the warehouse to the other. At the beginning of the production line, twelve new empty glass bottles are removed from their cardboard box and placed on the conveyor where they are washed, filled with wine and labeled. The empty boxes are then placed on a conveyor which transfers them to the end of the production line where the full wine bottles are returned into boxes. One of the bearings on a sprocket chain system was slipping causing the conveyor belt to stop moving. The overhead sprocket chain system was approximately 9 feet above the ground. In order for the employee to reach the system, he had to use a portable 8-foot A-frame ladder. It is important to note that the switch to deenergize the motor for the conveyor was approximately 20 feet away from the sprocket chain system. The employee had been making adjustments to the sprocket, but the sprocket kept slipping and stopping causing the conveyor belt to stop moving. The employee kept moving the ladder back and forth from the switch on the motor to the sprocket that was causing the problem. The employee pulled on the chain without deenergizing the machine. As he pulled on the chain, the sprocket began to spin causing the employee to catch his left hand in the nip point in the system. The employee amputated his index and middle fingers and was hospitalized.