Abstract: On September 20, 2004, Employee #1 was loading boxes onto a roller conveyor from a pallet at a paper box manufacturer. The conveyor advances with a foot-actuated pedal that was operated by a coworker who was working on the side of the conveyor opposite Employee #1. The coworker inadvertently actuated the foot pedal, while Employee #1 was leaning forward, loading boxes onto the conveyor. Employee #1's right foot was drawn into the pinch point of an unguarded chain and sprocket drive located under the side of the conveyor. He was hospitalized for the amputation of two toes. The employer had fixed a guard on the pinch point by the time the investigation was initiated.