Abstract: At 2:00 p.m. on October 9, 2020, an employee was working for a firm that made cardboard boxes for various consumer products. He was a machine operator. He was working in the finishing department. He was setting up a model number L2BDC Flexo-Folder-Gluer machine, with serial number 15400. The machine was not deenergized. The employee placed his right hand between two unguarded in-rolling rollers to make an adjustment to the folder portion of the machine. The machine started moving, and the employee's hand was crushed between the rollers. The employee was hospitalized. The firm's s managers knew that employees set up the equipment prior to each job. The managers stated that the equipment being used was quite old and that only trained employees operated the machinery. One manager stated that he was not sure why the employee went into the area that he did. Nonetheless, he stated the machine was not locked out and the employees were at the end of the set-up process. This manager had a third-party vendor come in and place guards with a chain and lock all around the equipment to prevent employees from being able to reach into the machinery. The manager also stated that it was company policy to lock out equipment when employees were performing any type of servicing or maintenance. The company provided lockout training to employees as affected employees but did not enforce that employees lock out the equipment out during the set-up process.