Abstract: On October 16, 1988, Employee #1 was working the 7:00 a.m. to 3:00 p.m. shift. He had been assigned to clean out the nitride brick quitter machine in the nitride building, an operation he had performed 20 to 30 times before. The brick quitter machine had been operating all morning. Employee #1 cleaned the mixer screws and chute and knocked the hard materials down into the cone feeder. After his lunch break, he had to turn the machine on to clean it since product had accumulated inside the cone feeder. He turned on the four switches required to properly clean out the machine, and then went to the top to make sure all of the product was coming out all right. Seeing that it was, he headed back down to the right side of the machine to check a leak he had seen earlier. As he was walking toward the machine, one of his feet struck something, probably a large hopper that was within a couple of feet of it, and he fell toward the machine. When he grabbed the lip of the conveyor with his gloved right hand part of the metal chain caught his glove and pulled his hand and arm into the sprocket. The chain and sprocket kept moving, cutting into the flesh on the employee's hand and arm. A coworker entered the work area, heard Employee #1 yelling, and stopped the machine. Another coworker cut the chain with a torch to free Employee #1's arm and hand. First aid was administered until an ambulance arrived. Employee #1 was taken to Union Memorial Hospital, where it was determined that he had sustained four badly lacerated fingers, a fractured wrist, and a severely lacerated forearm. The machine had not been properly guarded.