Abstract: At approximately 1:00 p.m. on May 13, 1991, Employee #1, of Container Management Services, responded to his manager's request to troubleshoot the conveyor line in plant #2 near the outside stripper rinse area. He de-energized the line and determined that the electrical system required new fuses. After replacing the fuses, he re-energized the system and decided to inspect the motor located under the subfloor. As he reached to touch the motor with his left hand, an unexpected startup of the system pulled his fingers through the chain. He sustained crushing injuries and lacerations to his fourth and fifth fingers. Employee #1 has at least ten years of electro-mechanical experience and has been employed at this location since January 1991. The motor, chain, and sprocket are enclosed in a fixed barrier to prevent employees from going near the nip points. The employer had provided training and did not have an unwritten policy for these tasks to be performed prior to de-energizing and tagging out the systems. Employee #1 was treated at St. Rose Hospital in Hayward and was immediately transferred to San Jose Medical Center for admission and surgery. He was discharged on May 18, 1991, and was allowed to return to work on light duty on May 30, 1991.