Abstract: At 8:30 p.m. on November 14, 2019, an employee was working for a firm that made medical and surgical instruments. She supervised mechanics and repair technicians. She was working in the facility's HA department, where the HA1 and HA2 robotic work cells were located. She was changing out a plasma spray gun from the HA2 robot. The robot was still energized. It had not been locked out. As she was loosening a bolt to detach the plasma spray gun from the robot, the wrench she was using contacted a metal fitting on the spray gun water line. An arc flash ensued. The employee received second-degree burns on two fingers on her left hand and on her right wrist. She was treated without hospitalization. The employee had not been trained on lockout or the use of padlocks. The interlocked access doors to the cell were equipped with a limit switch that did not deenergize the robot or the spray gun. The employee entered the cell two to three times daily. A risk assessment had not been performed. The employer was not enforcing energy control procedures.