Abstract: At approximately 4:30 p.m. on March 24, 1992, a plant of W.R. Grace Construction Products Division was experiencing intermittent problems with the Monokote Bagging Station's number 2 mixer. Employee #1, a 49-year-old shift lead/machine operator with 19 years of experience, was asked to observe the packer's Reed switch and make notes for the maintenance crew the next morning. The guard for the left packer belt was left off to allow observation of the dash pot containing the Reed switch. Employee #1 stood at the rear of the machine in operation to see if he could identify the problem. After he watched the machine fill three bags, his left hand was pulled into the belt and pulley. He suffered amputations of his left proximal, index, middle, and ring fingers and dislocation of the little finger. He was immediately transported to the local hospital and was admitted for emergency revision of all three amputated digits. A closed reduction was also performed on the little finger. The accident was probably caused by the guard being removed, thus exposing the belt and pulley assembly.