Abstract: At approximately 7:50 a.m. on January 15, 1992, Employee #1 was moving a bale of tin along a roller conveyor. This process involves hooking the bale with two hooks attached to a nylon rope that runs through a pulley. The other end of the rope is then wrapped around a pulley drum and pulled. The bale slides down the conveyor into position to be picked up by a forklift. As Employee #1 was following this procedure, the pulley broke away from its mooring, striking her in the leg and inflicting compound fractures to the lower left leg. The pulley failure may have been due to metal fatigue of some bolts or a weld that was not detected by inspection.