Abstract: At 4:30 p.m. on November 14, 2019, an employee was working as a machine operator for an aluminum foundry. She was cleaning the facility's core machine number 7 at the end of a shift. She had to reach into a bowl and shovel and sweep the floor. Cleaning took about 30 minutes. The machine was on manual. There were light curtains, perhaps five, on all sides of the core machine. The core department had six to seven employees in the core department, and they all did the same job. The employee went inside the machine. When she stepped out of the light curtain, the machine's head moved and went onto the employee's hand, bruising the hand, leaving a hematoma, and fracturing a finger. She was in the hospital for a few hours, but she was not hospitalized. The employee stated later that she had never locked out the machine. She said that the lockout training was awareness training. She had never been given a lock, had never locked the machine out, and had never been told to lock the machine out. She said that on the manual mode, the machine should not have been moving. When the CSHO inspected the scene, there was a lock sitting on top of the machine's disconnect box. The energy sources were electrical and air. The air had a valve that could be locked out, but no lock was available, and the valve did not have, as it was turned off, a matching hole to allow the lock to secure the handle movement. According to the company president, lockout retraining was done for each core operator following the incident. A new air valve was installed after the incident so that a lock could be used.