Abstract: On December 9, 2008, Employee #1, a mechanical contractor, was working in a chemical plant to service a reciprocating horizontal compressor, Model Number C106B. As Employee #1 placed a 2 inch by 4 inch wood spacer block inside the port opening of the deenergized reciprocating horizontal compressor, a coworker manually rotated the compressor flywheel in order to remove its piston. Employee #1's right ring finger became caught between the moving piston and the block, causing its amputation. The fingertip could not be reattached. The incident investigation determined the following three failures as to the cause of the accident: (1) poor communication in a noisy work environment, (2) no procedure in place, and (3) the inability to appropriately evaluate hazards associated with the work activity.