Abstract: On November 29, 1994, Employee #1 was installing a faceplate on an Okuma engine lathe PCN007010097, serial #4308-13390, at a Torus and Scrolls shop. With the help of a skyhook, the faceplate was positioned on the right-hand side of the chuck. One of the three holes on the faceplate was aligned with one chuck hole, and one bolt was positioned and partially tightened. The other two bolts were yet to be positioned. According to the shop manager, the speed was set at 24 rpm. Suddenly the faceplate and the spindle started rotating counterclockwise. The hook on the skyhook chain was still attached to the faceplate and it pressed Employee #1's fingers, amputating his little finger and injuring two other fingers. Before starting the set-up, he did not press the OFF button of the engine control box or of the control panel next to the lathe machine. The handle of the spindle control lever near head stock (F6 per manual) had been removed by management a long time ago. Employee #1 could have pressed the socket where the F6 lever rested with his foot, causing spindle motion. The only other spindle control lever on the right-hand side (C-26 per manual) might have been somewhat loose due to wear and tear, causing the lever to shift slightly and the spindle to rotate.