Abstract: On January 29, 1996, Employee #1 and a coworker, both contractor employees at a large metropolitan refinery, were asked to repair the normal elevating mechanism of a #10 coke drum. Since the Porta-Power single-acting hydraulic jack was not tall enough to reach the bottom head of the drum they wished to elevate, they used an 1-1/8 in. by 10 in. bolt set on the top of the jack's cylinder to achieve an adequate height. They were elevating the head when the jack and the bolt fell over, causing the head to drop on Employee #1's right hand. He sustained injuries that required that two of his fingers be surgically amputated. The two employees normally worked greasing and lubricating in the coke unit; this task was not part of their normal job responsibilities.