Abstract: IN A PLANT THAT MANUFACTURERS CORRUGATED CARTONS, SEVERAL OF THE ROLLER CONVEYORS ARE DRIVEN BY A "V" BELT THAT PASSES BENEATH THE CLOSELY SPACED ROLLERS (AND IN CONTACT WITH THEM) AND CAUSES THEM TO TURN. THE BELTS ARE FROM 6 TO 8 FEET LONG AND ARE 3/4 INCH WIDE. THE PULLEYS AT THE BELT ENDS ARE ABOUT 5 INCHES IN DIAMETER. BELTS ARE CHANGED WITH THE POWER OFF AND BY "SNAPPING" A SUFFICIENT NUMBER OF ROLLERS OUT TO GET TO AT EACH END OF THE BELTS. DESPITE A STRICT PLANT-WIDE POLICY AGAINST WORKING ON OPERATING MACHINERY, EMPLOYEE #1 ATTEMPTED TO INSTALL A NEW BELT ON A ROTATING PULLEY. THE TIPS OF THE SECOND AND FOURTH FINGERS OF HIS LEFT HAND WERE AMPUTATED. INTERVIEWS WITH OTHER MAINTENANCE PERSONS CONFIRMS THAT WORKING ON MOVING EQUIPMENT IS PROHIBITED. A LIST OF SAFETY RULES WHICH THE INJURED EMPLOYEE READ AND INITIALED WHEN HIRED IN 1986 INCLUDED ONE RULE FORBIDDING REPAIR ON RUNNING MACHINERY.