Abstract: At 3:30 a.m. on October 30, 2019, an employee was working as a machine operator for a firm that manufactured plastic material and resins. Accompanied by his supervisor, he was working on plastic extrusion line 3. A product run had just finished. The machinery needed to be reprogrammed to new specifications for the next run. This task took place two to five times per shift, depending on production needs. When the machine was reset, a startup procedure was necessary before the machine could be set back to full operating speed. An employee had to feed a plastic sheet through the machine's rollers by hand. The machine was placed into slow mode, in which the rollers moved at a minimal speed and were lifted so that an employee could thread the plastic. The rollers were then returned to their operating position, and the machine was turned back onto full speed. In this incident, as the employee was threading the plastic through the rollers, his supervisor went to the controls and pushed the button to lower the rollers back into their operating position. The employee's right hand was crushed between a pair of rollers. Hearing the employee cry out, the supervisor opened the rollers. He discovered the employee still inside the machine with a serious hand injury. Workers called emergency medical services. The employee was taken to the hospital, where portions of the middle and ring fingers on his right hand were surgically amputated. He was not hospitalized. Later, the supervisor said that he had lowered the upper roller after seeing plastic on the floor, usually an indication that the machine was ready to restart. The supervisor admitted that he had not checked to locate the employee first. Since the machine needed to run in slow mode for the threading, a traditional lockout was not possible. Additional measures, not in place at the time, were needed to protect an employee inside the equipment. A coworker could activate the controls while someone was still inside the machine.