Abstract: At 11:00 p.m. on November 25, 2019, Employee #1 was operating the small heat transfer machine (manufacturer D3 Products) to put decals onto t-shirt sleeves, which functioned as an ironing press. This is how the machine works: there are two stationary platforms, one on the left and one on the right to which the t-shirt sleeve is put into, and then a decal is placed on top of the sleeve. After this, a hot plate (about 6 by 6 inches) which is above the platforms, moves into position automatically to the left and right and then lowers into position onto a platform to apply heat and iron the decal onto the shirt sleeve. This process is on an eight-second timer for ironing, with the temperature set at 300F. After the eight seconds is complete, the hot plate releases upwards and travels to the opposite direction and then lowers for eight seconds, and the cycle continues. Employee #1 was expected to switch out the sleeves based on the eight second timing: if she fell behind, Employee #1 was told to physically hold a part of the machine to stop the movement of the hot plate while positioning the next sleeve and decal to be ironed. Employee #1 could not keep up with the eight-second timer, and was holding part of the apparatus with her left hand so that she could finish putting the sleeve and decal on the platform on the right before the iron would lower into position. Employee #1's right hand became caught between the platform and hot plate. Eventually, Employee #1's right hand was freed from the machine by coworkers. Factors that contributed to this accident were that this small heat transfer machine was not guarded as required, and that the compressed air line was disconnected which prevented the hot plate from moving. Employee #1 was hospitalized until December 12, 2019. Employee #1 sustained third-degree burns on her right hands, pointer, index, middle, pinky and thumb. Employee #1 also had about seven to eight surgeries.