Abstract: At approximately 11:00 p.m. on February 25, 2014, Employee #1 was working at a refinery and for a company that was engaged in construction and engineering services. He was assigned to assist a coworker, the mix operator, at a rig on the refinery site. Employee #1's duties consisted of cleaning up of a mix station, pre-weighing of the stainless steel fibers used to reinforce a mortar spray material and ensuring an adjacent water barrel was full of water to pre-dampen the material to keep dust to a minimum. The coworker's duties consisted of operating the mixer, ensuring the correct amount of material was mixed, pouring the pre-dampened water and stainless steel fibers for each bag of material mixed and completing a mixing log to document what materials was being installed and the location where it was installed. Another coworker, the gunite machine operator, was located at the opposite end of the rig from the mixer. The gunite machine operator's only communication between Employee #1 and the coworker was to inform them to continue or to stop the mixing hopper so that the hopper stayed full for the gunite operation. At approximately 11:00 p.m., the mix operator allowed Employee #1 to work the mixing operation. The mix operator instructed him to place six bags into the mixer with the grate down and the blades moving and then add the water. Employee #1 reported that the gunite mix was becoming stuck on the sides of the mixer and so he lifted the grate guard and tried to clean the outer upper portion of the mixer with a trowel. He did that because he had observed the mix operator doing the same thing beforehand. As he cleaned the mixing drum, the mixing paddles (blades) caught the trowel and pulled his hand into the mixer. During this time, the mix operator was filling out mix logs and did not observe Employee #1 working. Just as Employee #1 pulled his hand away the mix operator walked by and saw Employee #1 holding his hand. The mix operator turned off the rig and used his radio to summoned emergency medical personnel. The gunite machine operator and the mix operator walked Employee #1 over to where their tool room was located. Employee #1 was transported via a company van and was escorted to a medical office and then was transported to a medical center, where he was hospitalized. Employee #1 suffered severe injuries to his fingers on his right hand requiring multiple surgical procedures and still suffers from lost mobility of his fingers. The supervisor was not in the area when the incident occurred and did not observe it. Causal factors were Employee #1 did not receive any new employee training nor did he receive any training prior to being assigned to working on the rig, where he was assigned; the employer did not have any method to prevent entry into the mixing drum by means of a tool to remove the mixing guard nor did the employer have any accident prevention signs or tags placed on the controls of the power source as required by regulations or the manufacturer's recommendations; and, the employer did not ensure that the equipment was blocked or mechanically locked out prior to allowing employees to clean the mixing drum.