Abstract: At approximately 9:30 a.m. on July 14, 2003, Employee #1 and a coworker were installing 0.875-in. by 9-in. Allen head bolts in the number 4 line triple manifold. The usual procedure was for Employee #1 to manually install the bolts, and to hand tighten them a few threads. Then a coworker would use the pneumatic wrench to tighten the bolts completely. At the time of the incident, they changed their procedure. Employee #1 was holding the bolt while the coworker used the pneumatic wrench to start and tighten the bolts. The manifolds and bolts were very hot so thermo gloves were used to protect the hands. The glove of Employee #1 got caught and his left index finger was smashed between the shoulder of the bolt and the line 4 triple manifold. Another coworker transported Employee #1 to the medical center clinic where Employee #1 received first aid treatment and was then sent to the Western Hand and Orthopedics Center in Downey, California. Employee #1 sustained an amputation of the tip of his left index finger. He was not hospitalized.