Abstract: At 10:45 a.m. on April 8, 2020, an employee was working as a machine operator for a wholesaler of dairy products. English was not her first language. She was working in the facility's filling room. She was working the PacTec line. A 2008 PacTec model PT-4/6S filling machine, with serial number 2201, was filling cheese cups with product. During the preceding shift, an issue had arisen with the machine, in that it was not able to maintain the correct temperature. After this problem continued, the employee contacted her supervisor and advised him that the temperature was still too low. The supervisor instructed her to shut everything off and rinse it. This was the first rinse process of the day. The employee shut off the cooker so that product would not come into the industrial stainless steel filler hopper that was part of the PacTec machine. She went to the control panel and shut everything off and pressed the E-stop button before starting the rinse process. She then went up onto the platform where the filler hopper was and grabbed a water hose from the wall and a scrapper. The agitator, which was located inside of the hopper, was not controlled by the E-stop and continued to rotate at a slow speed. As the employee cleaned out the hopper, she became caught in the machine. There were no direct witnesses, but employees in the area, hearing her scream, came to her aid. The supervisor was called over. He shut off the agitator, ran up to the platform, and assisted in removing the employee and bringing her off the platform. Emergency medical personal came to the site and provided medical treatment before transporting the employee to a local hospital. The employee had suffered an injury to her right arm and burns to her chin, neck, and shoulder. She was hospitalized. She had not been trained to the authorized level to do this work.