Abstract: At approximately 6:00 a.m. on October 1, 1999, Employee #1, a 32- year old bakery supervisor, lost the tip of his index finger when he attempted to repair and adjust a dough divider machine without first turning the power off. Employee #1 served as a supervisor for about one year. Employee #1 was very familiar with this machine, because he worked in this area of the bakery for about twelve years. The conveyor belt was not running at the beginning of the shift. The supervisor removed the front panel and had a towel on his right hand when he attempted to pull on the stopped belt. The belt began to move, and the towel became caught in the gears pulling his right hand into the gears. Before Employee #1 could pull his hand free, his right index finger was amputated at the tip. He wrapped his hand and the recovered finger tip in a clean towel. Another supervisor drove Employee #1 to a local trauma center for treatment. The surgeon was unable to re-attach the tip of the finger. Employee #1 was released about 11:00 a.m. Employee #1 received training on the use of the company lock-out/block-out procedure several times over the past 10 years, including his most recent training on July 1, 1999.