Abstract: At 2:45 a.m. on October 16, 2019, an employee was working as a machine operator for a firm that packaged pharmaceuticals. He was working in the printing department. He was rewinding foil paper through a Komori printing press machine. One of his fingertips became caught between rollers on the machine. His fingertip was partially amputated machine. He was hospitalized. Rewinding foil paper was a task that was done several times every day. Employees used the machine's jog button to do this. The injured employee's fingertip became caught when the machine was in the jog mode. The machine was equipped with interlock guards. The guard was open when the employee was attempting to rewind the paper, but he was still able to use the jog button to perform the task. The employee did not lock the equipment out prior to performing the setup task. He had not been provided with lockout/tagout training as an authorized employee.