Abstract: EMPLOYEE #1 WAS CLEANING OUT THE LID TRIM AREA OF A BROWN ULTIMA THERMOFORMER MACHINE (MODEL 20-20), USING COMPRESSED AIR AND A SCREWDRIVER. WHEN HE FINISHED THE JOB HE CLOSED THE LEFT SIDE DOOR, WHICH AHD A SAFETY CUT-OUT SWITCH ATTACHED TO IT, AND LEFT THE RIGHT SIDE DOOR OPEN. THE RIGHT SIDE DOOR DID NOT HAVE A SAFETY CUT OUT SWITCH ATTACHED TO IT. HE WENT TO VISUALLY INSPECT THE LID TRIM AREA AND INADVERTENTLY PLACED HIS HAND INTO THE PRESS AREA. TWO FINGERS ON HIS RIGHT HAND WERE AMPUTATED AT THE FIRST KNUCKLE. THE EMPLOYEE HAD RECEIVED 45 DAYS OF ON-THE-JOB TRAINING. THERE WERE NO WRITTEN SAFETY AND HEALTH RULES FOR THE TASK BEING PERFORMED.