Abstract: At 2:07 p.m. on October 21, 2021, an employee was working for a firm that made metal cans. He and a coworker were performing a coil change operation on a Perfecto model 500-72 lubricator, with serial number 87073. It was on the site's line 1. Other lines had the same model lubricator. In this operation, aluminum from a coil was being fed through a machine. This was an operation that was performed on the firm's four lines about twelve times per day. In this incident, the aluminum from the coil bunched up while the two employees were feeding it through the rollers on the front end of the lubricator. The employees had to reverse the machine to get the aluminum coil out the machine and try to feed it through again. Although changing coils was a routine event, taking a loop out of a coil was not a routine event. The coworker was operating the controls while the employee had his hand on the aluminum coil. There was no guard for this part of the machine. The coworker put the machine into reverse, expecting that he could use the jog button to control the movement of the aluminum. Instead, the machine went into reverse right away. The employee's right hand was pulled into the machine. His right index finger was amputated, his thumb was crushed, his palm was ripped wide open, and the skin and flesh of his fingers were taken off. He was hospitalized. The reverse button was malfunctioning. It should not have automatically engaged as soon as it was put into reverse. The employees had been expecting that they could manually control the machine in reverse using the jog button. The firm had been aware of this malfunction since August 2021 and had issued a safety hazard notification On August 19, 2021. Its electricians had not been able to determine the root cause of the issue. The firm had decided to build a new control system. They ordered the parts on September 3, 2021. The wiring and controller had been built, and the firm was waiting for the new control panel to arrive.