Abstract: At approximately 8:45a.m. on Jan 2,2018, a 50-year-old male was working as a machine operator for a manufacturer of plastics products. He was a full-time, regular employee and worked for the firm almost 20 years. He was working on the first shift in the extrusion department. He and a coworker were setting up a portable plastic sheet shear on Extrusion Line Number 1.It was normal for two operators to assist each other during setup.The shear was plugged in to an electrical energy source and turned on, but not running.A slowly moving continuous plastic sheet was coming from Extruder Number 1.It had to be guided toward and through the pull rollers on the shear. Initially, both workers were standing between the extruder and the shear.The coworker cut the sheet with a knife and folded one end at an angle.The employee walked away from the sheet to the other side of the shear to receive the sheet.He stated that he did not walk by the side of the shear with the operator's control station and that he did not press the controls to initiate any functions, such as activating the cutter or opening the pull rollers. He stated that the pull rollers were already vertically a few inches (several millimeters)apart. This opening was necessary for the coworker to feed the folded point of the material into the shear.The employee was standing in a forward-leaning, slightly bent position, with his arms extended toward the point of operation.He held a small brass scraper in his right hand to guide the sheet through the shear.His left hand was positioned to receive the sheet once he had pulled it through the rollers with his right hand.His right hand was immediately next to the point of operation.As he guided the sheet through the shear's cutter area, the tip of the index finger on his right hand was in the point of operation, directly under the unguarded cutting blade.The horizontal cutter blade unexpectedly cycled, moving down against its lower permanent fixture and back up.Immediately, the employee sustained a complete distal phalanx amputation of the fingertip.He yelled to his coworker that his finger was cut.He folded his right hand into an upright fist, with his left hand covering it.After the coworker told the employee to seek first aid from CPR-trained personnel and stopped the machinery, the employee walked away from it.Other coworkers called emergency medical responders.The employee was taken by ambulance to a local hospital emergency room.He was not hospitalized.The cause of the unexpected startup was unknown. A system malfunction or failure, such as a short circuit, could have occurred, sending an erroneous signal.It was also possible that the employee or coworker initiated a function at the operator's control panel, causing the activation.Pressing the red open button would have caused the pull rollers to open.This step would have caused the counter roller, in direct contact with the top pull roller, to turn.An input signal sent from the counter roller, measuring the progress of the plastic, would have initiated the cutting cycle, as if the required length of sheet had been fed through the shear, and that the sheet was ready to be cut.Other possibilities included a malfunction or failure, or the operator's intentional pressing of the function controls at the control panel to carry out setup tasks.Management representatives claimed that no deficiencies were found in a post-incident inspection that would have resulted in an unexpected, unintended, or uninitiated cycle activation.Although there was no need for the shear to be energized during the feeding part of the setup, machine operators were not required to deenergize the shear by disconnecting its cord and plug.The employer did not recognize machine operators as authorized employees under the company's lockout program, but it did require them to perform servicing tasks of limited scope, such as setup, without deenergizing the machine.