Abstract: On September 13, 2006, an employee ("palletizer attendant") operated palletizing machines. The palletizer attendant used a forklift truck to place wooden pallets into the magazine racks of the palletizers. The machines then lowered one pallet at a time onto a conveyor, and sugar products were automatically loaded onto the pallets. After the palletizer attendant placed pallets in the machines, he monitored the operation for potential problems. The attendant checked the quality and condition of the pallets being used and removed damaged ones. Prior to the accident, the company received more than the normal number of defective pallets from their supplier. When a defective pallet was inadvertently used, broken pieces of wood got wedged in the machine, causing the palletizer to jam. The palletizer attendant was working in the Finishing House, when the machine alarm sounded for the Number 1 Lamson Palletizer. The attendant determined that there was a jam and removed all but two pallets from the dispensing magazine of the machine with his forklift. The employee climbed off the forklift, walked to the pallet dispenser, and by hand, removed one of the two pallets still in place. He then placed his right hand on the bottom board of the jammed pallet and pulled it up. As he was doing that, the pallet shifted upwards and pinned his hand against the machine frame. Since the machine had not been deenergized, the force of the pallet-lifting device moved the pallet in an upward direction. After the machine was deenergized by a mechanic, the employee was able to remove his hand from the palletizer. He was given first aid and then taken to a hospital. He suffered two fractures to the bones on the back of his right hand and received 12 stitches. There were no written procedures to describe the actions employees where to take when a jam occurred.