Abstract: At 3:30 p.m. on September 23, 2020, an employee was working for a company that manufactured mattresses. He maintained machinery. Among the firm's equipment was blow fill machine part 5, a Qingdao ClusterLoft Co., Ltd. model number T01EB-100 fiber opening blow fill machine, with serial number 18QL10009B. The machine ran on 480-volt 60 Hz 3-phase power. Its main rollers turned at 500 to 600 rpm. The machine had been at the company for about a year. It got clogged once or twice per shift, depending on the weather. The procedure for unclogging the machine was first to turn the power off at the circuit breaker box on the side of the machine and then to lock out the circuit breaker. The machine had a hinged plexiglass access door. Opening the door initiated the machine's stop process. The machine took about one minute to come to a complete stop. The machine was clogged now. The employee was unclogging it. He had last cleaned the machine five or six days earlier. The employee began by locating the clog. He had not locked out or tagged out the machine. The machine was supposed to feed material into a silo, but the silo was empty. Seeing that the feed rollers that grabbed fiber and tore it were not clogged, the employee checked elsewhere. He could not see or hear the machine running. Parts inside, though, were coasting to a stop. Even with the machine at a complete stop, a big feed roller on the inside was still spinning. The employee removed a safety guard and reached into some ductwork with his left hand. Not feeling anything, he reached in farther. He heard something fall on the floor. His left hand had been struck by a "carded" fiber processing roll. He snatched his hand out from the hole and saw that all five fingers had been amputated. The employee was hospitalized. The maintenance supervisor, working nearby but out of sight, knew that the machine was not locked out or tagged out. The employee had learned how to clean the machine by watching the maintenance supervisor.