Abstract: On April 29, 2010, Employee #1, a valve seal wrapping machine operator, was stopping the flow of the valve seals (small metal rings) on the wrapping machine with her hand. As the spindle indexed around to catch the parts, her hand became entangled between the spindle and the end stop for the slide (chute). The web of her hand was cut, requiring stitches. The incident investigation revealed that the employer had unsuccessfully attempted to guard the spindles or redesign them. No guarding was in place at the time of the accident and due to the wrap repeatedly jamming, it was necessary to manually index the spindles.