Abstract: At 9:40 a.m. on April 20, 2002, Employee #1 was performing preventative maintenance on a palletizer full pallet conveyor (transfer discharge). He stated that he usually locks out machinery at the main panel; however, on this day, he decided to activate two emergency stop switches on the palletizer, assuming that the transfer discharge would turn off. He wanted to run the sprockets to clean all the parts and thought that it would be easier and faster to turn off the machinery with the emergency stop switches. As he lifted the guard for the sprockets of the transfer discharge, his arm activated the photoelectric eye. This activated the transfer discharge and Employee #1's left gloved hand was pulled into the sprockets, causing the amputation of the tip of his thumb. The accident investigation noted that Employee #1 received general safety training, including lock-out, block-out.