Abstract: Employee #1, the operator of a Stokes Pacer vitamin pill compressing machine, was cleaning a revolving plate inside the machine housing, a procedure that was done approximately five times per week. His left hand contacted the revolving plate, resulting in fractures and lacerations to his index and middle fingers. Employee #1 did not unplug the plate prior to starting work, as required by the company's operating procedures manual. He had been trained in proper machine operation and cleaning procedures, and on September 19, 1990, his supervisor had warned him about cleaning without de-energizing the machine. Immediately after the injury, and before the investigation, the employer installed a key-controlled electric lockout switch, controlled by the supervisor, to prevent recurrence of the accident.