Abstract: At approximately 10:00 a.m. on May 16, 2006, Employee #1, an operations manager, was adjusting the strawberry-machine chain to align and time the left and right chains. The left and right chains became unsynchronized, resulting in a misalignment of the boxes traveling through the strawberry machine. This misalignment occured up to 10 times during a work day, when the roller chain skiped a tooth on the sprocket. Employee #1 had realigned the chains on many occasions by placing a bolt between the chain and sprocket, while the machine was running, to cause the chain to skip a tooth on the sprocket to synchronize the left and right chains. While Employee #1 placed the bolt into position, the knee brace he was wearing came into contact with the start switch. The machine started and caught Employee #1's right index finger between the chain and sprocket and crushed it. Employee #1 was taken to the hospital where his right index finger was amputated at the first knuckle. Employee #1 was not hospitalized. The established procedure was to stop the machine, place a bolt between the chain and sprocket at the point where the chain and sprocket meet. The bolt was then to be held in place by hand, and then the machine was started, when the bolt was wedged between the chain and sprocket, the bolt was released, and the hand removed.