Abstract: At 2:10 a.m. on March 11, 1991, Employee #1, a mechanic, was retiming the B-line Spaghetti-Os dropper, which puts Spaghetti-Os into 15 oz cans. The retiming occurred in two phases, the first of which required electrical power. The second phase was the fine tuning of a manually adjusted screw within a chain and sprocket drive from which the guard had to be removed. Although proper lockout procedure was used throughout most of the phase 2 adjustments, at a certain critical point the power was interrupted by a magnetic safety interlock device instead of disconnecting lockout. A coworker inadvertently dropped a nickel can, which allowed a magnetic contact to initiate power to the machine. Employee #1's hand was caught in the shear point, amputating his right index finger. He was taken to Methodist Hospital, where efforts to surgically reattach his finger were unsuccessful.