Abstract: On December 27, 1989, Employee #1 was transferring frozen food cartons from a pallet to a conveyor that feeds a lane loader. The end of the conveyor (which employs bar rollers) includes an emergency switch used to shut down the conveyor section, when necessary. There was a 10-in. space between the bar and the control panel. The first roller was missing and on its place, the space was reduced to 6 inches. Some cartons fell off the side of the conveyor or fell through this gap to the level below, a distance of 6 feet. There was also a 2.5-ft. die sprocket (no chain) on the end of the roller, located 30 inches from the user's side of the conveyor. There was also a crossbar about 2 feet below the end of a falling carton. At the beginning of the third shift, a carton fell part way. Employee #1, who knew nothing of the sprocket wheel on the end of the roller, attempted to retrieve the carton without shutting down the conveyor. The employee wore cloth gloves and was working in an awkward position. The sprocket caught his glove and, in seconds, began wrapping and tearing it. The glove was quickly cut through and the inside of Employee #1's right forearm was deeply lacerated. The line was stopped. Emergency Medical Team personnel, who are on each shift, quickly attended him. Employee #1 was taken to a local hospital. A collar replaced the sprocket and the first roller was reinstalled. Employee #1 had worked in the frozen food warehouse (distribution) for the supermarket chain for 6 years. The warehouse is highly automated and computer-controlled. However, some equipment is manual, including a depalletizer. During this 6-year period, Employee #1 had performed work on this unit off and on for periods of a month of more.