Abstract: On December 13, 2005, Employee #1, a machine operator, was working in a facility that manufactures residential commercial tanks for water softening and filtration applications. A tank is a composite design of a single piece of seamless inner liner over wound with a continuous epoxy and fiberglass laminate. The over winding of epoxy and fiberglass is produced by a machine called a winding machine. An inner liner is placed upon two rotating shafts within the machine as fiberglass thread is weaved over it laterally and transversely. The carriage component of the machine generates the transverse motion. The fiberglass threads are pulled from a resin soak stand with the assistance of a resin roller and fiberglass guide arm. Before cleaning the machine parts and carriage with acetone, Employee #1 placed the fiberglass rolls on the floor, a cardboard in front of the machine and the residue catching tray of the carriage to catch cleaning residue. The residue catching tray was located near a rotating shaft. As Employee #1 worked near the tray, his loose and front split open shirt was caught in the rotating shaft, pulling him across the floor. Another coworker stopped the machine. Employee #1 received upper right arm fractures, and back and leg injuries. He was transported to a hospital for medical attention and later on discharged that same evening. Two days later, Employee #1 was hospitalized a medical center for a period of two days for necessary surgery. An investigation of the facility found that the employer did not use lockout, tagout program while doing adjusting, cleaning and servicing operations at the beginning of the shift.