Abstract: On March 18, 2011, Employee #1, a mechanical engineer, was standing on a platform containing 16 gear pump motors. He was standing between two pump motors, doing repairs on the motor in front of him. The pump motor he was working on was powered off, but the motor behind him was not. As he worked on the pump motor, his shirt became caught in the slow rotating shaft of the unguarded pump motor behind him. Employee #1 tried to remove his shirt, but was unable to untangle it from the shaft. A nearby coworker tried to assist him, but was unsuccessful. Another coworker ran downstairs to power off the pump motor that had entangled Employee #1's shirt. Before the coworker was able to power off the pump motor, Employee #1's arm was amputated at the elbow. Another coworker called emergency services and began first aid on Employee #1. The amputated part of his arm was placed in ice and transported to the hospital with him. Employee #1 was hospitalized for treatment. None of the 16 gear pump motors rotating shaft was guarded.