Abstract: On September 2, 1995, Employee #1, of Polycarbon, Inc., Valencia, CA, was changing the bag on a vacuum collection machine for scrap graphite from the carbon fiber and graphite production machinery when he noticed that material was stuck in the hopper. In order to free the jammed scrap graphite, he inserted his right hand into an outlet without shutting off and locking out the rotating valve inside the outlet. A guard at the bottom of the outlet designed to keep employees' hands away from the rotary valve had been removed. When Employee #1 reached into the outlet, his right index fingertip made contact with the rotating vanes of the rotary valve, causing a severe laceration and subsequent amputation of the first joint of the right index finger. The causal factors for the accident include the failure to ensure that the guard on the outlet was in place and the failure to de-energize the rotary valve before reaching into the vacuum system discharge outlet.