Abstract: At approximately 7:15 a.m. on October 24, 1990, Employee #1 and his foreman were replacing a broken bolt on a #20 Wafio nail making machine. The Allen wrench they were using fell and they could not find it. They replaced the bolt with another wrench and started the machine after removing the lock and tag. The machine was functioning normally and the foreman left. Employee #1, who was wearing leather gloves, reached into the machine with his left hand to retrieve the missing Allen wrench. There was a small opening in the guard covering the pulley and belt drive, and Employee #1's glove became caught by the mechanism. His hand was pulled inside and his index and middle fingers were amputated.