Abstract: At 4:30 a.m. on October 17, 2000, Employee #1, a pipefitter for a contractor in a large metropolitan refinery, and coworkers were lining up two sections of 52 in. diameter pipe to be welded. They had driven two steel plates under the pipe to move it and, for additional movement, had driven a wedge between the two plates. After they aligned and secured the pipe, the foreman told Employee #1 that the wedge and shim plates could be removed. Employee #1 was using a hammer to pound on the wedge and placed his left hand near the shim plates for balance. The tips of his index and middle fingers extended into the gap between the plates. The wedge came out suddenly and the two shims came together, crushing and amputating the tips of Employee #1's two fingers. He was hospitalized for treatment of his injuries.