Abstract: At approximately 1:30 a.m. on October 13, 2001, Employee #1 and several other employees were working for Montebello Container Corp. Two employees were repairing and adjusting the centering device for a unitizer stacker. The centering device is driven by two separate chain drives and was not closing evenly. One side of the device would close before the other causing the pallet to be cocked as it traveled down the conveyor. Before one of the employees left, he told the other employee that he would need to advance the chain one link so the device would center evenly. That employee said he told a third employee to operate the centering device in manual mode and told employee #1 that he did not need to manually push the pallets to get them square on the conveyor since the centering device was being operated in the manual mode and not in the automatic mode. In manual mode, the operator controls the centering device by activating a switch when the pallet is in the correct position. In automatic mode, a sensor controls the closing of the centering device. An employee continued working on the chain and sprocket drives for the unitizer stacker centering device and all four of the chain and sprocket guards had been removed. The employee quit working on the centering device and went to investigate a mechanical problem with another piece of equipment. Employee #1 said he was not informed that he did not need to manually push the pallets to get them square and was in the process of pushing a pallet when his left foot got caught between the unguarded chain and sprocket. Another employee saw Employee #1 fall down and stopped the unitizer stacker conveyor. The employee then activated the closing of the centering device freeing the left foot of Employee #1. Employee #1 was driven by other employees to Whittier Presbyterian Hospital where he spent at least 10 days in the hospital due to cut tendons, broken bones in all toes, and an amputation of the little toe of his left foot.