Abstract: At approximately 11:00 p.m. on February 9, 1995, Employee #1 arrived for work. A coworker informed him of a textile machine malfunction in which the fabric feed on one side of the machine exceeded that on the other. Employee #1 told the coworker to cut the fabric across the width so that he could begin to adjust the machine. Employee #1 thought the reason for the uneven speed was a particular bolt and, before the machine had shut down, he took a wrench and began trying to loosen it. The machine's moving chain caught the other end of the wrench, pulling a finger on his right hand into the space between the wrench and the steel bracket and amputating the tip. Employee #1 shouted for help; the coworker, seeing what had happened, stopped the machine. Causal factors in this accident were the failure to stop the machine completely prior to starting the adjustment, the failure during training to establish a need for lockout, and the failure to follow appropriate lockout/tagout procedures.