Abstract: At 11:52 p.m. on April 9, 2019, an employee was working for a firm that manufactured nutritional supplements. She operated an Image filler machine in the facility's room 120. She ran various products as needed. She was using a vacuum to perform a light cleaning of the filler machine to remove excess product from the chain conveyer table. She applied pressure with the vacuum and unintentionally knocked the conveyor chain off its sprocket. The machine was still running. She attempted to replace the chain on the sprocket with the machine powered up and no lockout/tagout (LOTO) applied. Her fingers became caught, and three fingertips were amputated. She was hospitalized. During interviews with workers and management, it was established that workers performed a service cleaning of the Image filler machine between runs of similar types of batch products while it was still energized. The program did not address service cleaning on energized equipment or machinery. The employee, the machine operator, participated in an interview. She stated that the machine was not isolated during a light cleaning service. The firm's maintenance equipment manager participated in an interview. He stated the company did have a lockout/tagout program. Training was conducted within the company in a classroom setting only. All employees received training on what the lockout program was and how it was to be used. He stated that the Image filler machine was isolated only during deep cleaning, during which the machine was taken apart and deep cleaned and serviced. During a light cleaning the machine was not isolated.