Abstract: At 2:30 p.m. on January 23, 2019, an employee was packaging blood product standards on a Tiromat #2 machine. The machine jammed at the point where plastic sheets were molded to hold small standard containers. The employee pressed the emergency stop on the control panel, disconnected the electrical and hydraulic lines from both the top and bottom plates and donned gloves. The bottom plate was crooked, so the employee tried to use his hands to unjam the plate. The plate would not budge, so the employee decided to remove and replace the plate. He had his hands between the plates when the hydraulic plate moved upward and crushed his hands. He was hospitalized with a broken right ring finger, nerve damage and severe burns to his left hand.