Abstract: At 5:45 a.m. on October 30, 2019, an employee was working as a machine operator for a firm that manufactured plastic bags and pouches. She was working on the facility's Line 18LD8. She was operating a Cooper Machine & Tool Co. model CF-12 bag folder, with serial number 05-175. The machine been installed fourteen years earlier. Using a conveyor and air, it folded trash bags in half twice. At the time of the incident, a trash bag had jammed between the conveyor and the bag folder. The employee was pulling it out through a 1.5-inch (38 mm) gap between the conveyor and a machine guard. The conveyor was 12 inches (300 mm) wide and 5 feet, 5 inches (1.65 meters) long. The guard that covered the folder was 7 inches (178 mm) long, 14 inches (356 mm) wide and 4.3 inches (109 mm) tall. The conveyor pulled her gloved hand through the gap. She suffered the amputation of her right ring finger at the first knuckle. It was not clear whether she was hospitalized. During interviews, employees stated that they operated the bag folder up to twelve hours per day. The bag folder would jam, depending on the thickness of the trash bag being folded. Bags were between 1 and 1.7 mils (0.025 to 0.043 mm) thick. The thinner bags and the thicker bags were usually the bags that jammed in the folder. The employees would try to pull jammed trash bags out of the machine while it was running. They did not unplug the machine while removing the jammed trash bag. If that did not work, they called their lead operator. The lead operator would then remove the machine by unplugging it and putting another folder in its place. Due to the inadequate guarding of the in-running nip point, employees were exposed to getting caught in the gap between the top and bottom rollers when clearing trash bag jams.