Abstract: At 9:00 p.m. on September 20, 2021, an employee working for a staffing service was working as a packer for a company that provides custom packaging of prepared vitamins and supplements. The employee was operating the Dasong Stick Pack Machine D-19. The machine operates by placing powder in a hopper which fills packages with 4-inch by ?-inch small flexible plastic tubes. A heated die element then pinches and heat seals the top and bottom edges of the packages. Following this, the packages go into a basket and then go to quality assurance for inspection before being boxed. A coworker who was the employee's supervisor was the quality control technician on the second shift. The coworker assigned the employee to operate machine D-19. The employee said it was the first time she had operated this particular machine. She started running the machine at approximately 4:00 p.m. The employee said the machine had issues, was dirty, and the heated die blade that seals and cuts the stick packs jams and does not seal correctly. She also said there was no maintenance technician free on the shift to address the issues. The employee also stated that the interlock on the machine did not work so she was running the machine with the door open. The employee said she pushed the stop button, but it did not work, and that she had not been trained about how the emergency stop button functions. The employee placed her right hand into the machine try to remove jammed material and to clean the machine. The employee said she thought the machine was off as she tried to clear the debris and powder but the die blade closed on her index fingertip. The employee did not know about LOTO and that she had no training on LOTO. The machine had no guarding on the sides and top of the danger zone and the die blade could be contacted. The employee was wearing nitrile gloves and a surgical mask while operating the machine. The employee was hospitalized to treat an amputation to her finger requiring surgery.