Abstract: At 4:30 a.m. on March 16, 2021, Employee #1 was working at the Stanpac Flex-E-Fill ice cream packaging machine, preparing the machine for operation at the start of the day. She manually checked the alignment of the dispensing hole of the inner plunger with the outer cylinder of the ice cream fill valve with her left hand prior to starting the machine. She then started the machine and again attempted to check the alignment by reaching up into the fill valve cylinder opening with her right hand. The pneumatic cylinder that operates the fill valve cycled, and, as the dispenser opening closed, the middle fingertip on her right hand was caught in the pinch point between the inner plunger and outer cylinder. The end of the middle finger on her right hand was amputated. She was admitted to the hospital and received surgery to reattach her fingertip and spent seven days in the hospital. CalOSHA identified several causal factors including but not limited to: The machine was not under lockout / tagout while the operator was checking the adjustment of the ice cream fill valve. The employer had not performed periodic inspections of its lockout / tagout program. The machine did not have guards in place to prevent access to the reciprocating ice cream fill valve.