Abstract: At 8:10 a.m. on May 8, 1990, Employee #1, of C. M. S. Gilbrith Packaging Systems, was using a rotating abrasive disc machine to grind chamfers onto a 4 in. square piece of 1/2 in. thick steel. He was holding the plate in both hands. As the narrowed edge of the plate entered the gap between the abrasive disc and the work table, the plate flipped up against the abrasive disc, trapping his right thumb and amputating the tip. Neither Employee #1 nor a witness could remember how far the work table was from the abrasive disc; three weeks before the accident had been adjusted to 1/16 in. The machine was adjusted properly when it was inspected.