Abstract: At 9:30 a.m. on December 3, 2020, an employee was working for a firm that manufactured conveyors and conveying equipment. She was a temporary assembly worker. The narrative did not say whether she had come from a temporary staffing agency or had been reassigned from duty elsewhere in the firm. There was no second UPA. The employee was operating a two-hand control swager or swaging machine. It was a kind of hydraulic press. The employee would place a plastic conveyor connector inside the metal tube. The machine would then crimp the metal on either end of the tube to keep the plastic connector in place. The time, the tube was pulled out of alignment. When the employee put the tube back into the proper alignment within the tube clamp, her right middle finger was caught inside the clamp and amputated. The employee was hospitalized. It was known that the two-hand control device had never functioned properly. Three other employees who all used the swager machine said during their interviews that when they removed their hands from the two-hand control device, the swager would continue to operate. Two of these employees explained that there wasn't any other guarding, and that the two-hand control device never stopped the swager from operating, even when they removed their hands from the two-hand control device. The firm's chief financial officer said in an email that the firm had begun using the swager in October 2020. The vice president of operations said during his interview that he had worked on the swagger when it first arrived. When he used the machine, it would continue to cycle, even when he removed his hands from the control device. He added that there were no other guards. During the walkaround, the CSHO was led to believe by the warehouse manager that the control device had initially worked, but that it had malfunctioned. The employer had put the machine into service knowing that it was not functioning correctly. The employer explained that this was a new company.