Abstract: On August 19, 2002, Employee #1, a janitor, was requested by his supervisor to assist the Depal machine operator with a pallet that had slipped past the elevator chute opening, preventing the hoist from moving upward. Employee #1 pushed the pallet back into the elevator chute, but before he was able to remove his gloved hand, the operator began to raise the elevator carriage, catching Employee #1's thumb between the pallet and the side of the elevator chute. He was able to pull his hand free from his glove, but the inner side of his thumb was avulsed down to the bone. He was hospitalized with his injury. The employer later stated that Employee #1 failed to use the bar provided at each station. According to the employee, he had not been trained to use the bar and had learned the process by observing coworkers, who had used only their hands.