Abstract: At approximately 2:00 a.m. on May 6, 1999, an employee was injured at Atlas Carpet Mills in Commerce, California. The employee was working on tufting machine Number 19 trying to retrieve a broken yarn. The machine was energized and the fingers of the employee's right hand were caught in the fluted in-running nip puller-rollers, which pull thread into the machine. The employee incurred extensive traumatic finger crush injuries, which led to the amputation of the right index, ring and small finger from the base of the palm and serious lacerations to the bone of the second digit. The company is engaged in manufacturing carpet from yarn. This includes purchasing yarn, tufting carpet, finishing and distribution. The company produces approximately 20,000 square yards of carpet per day. Upon interviewing the employer, the employee, witnesses and investigating the actual accident site, it was determined that the serious injury that resulted from the accident may have resulted due to the victim not fully understanding safe machine guarding and the hazards of the mechanical motions and actions of the tufting machine.