Abstract: At 9:00 a.m. on November 10, 2021, an employee was working for a firm that manufactured plastic products. He operated extruding and forming machines. During this incident, he was operating the firm's number 18 thermoforming wheel. The machine was operated by two operators each using two-hand controls. The controls for the wheel required two-hand control by each employee to lower four clamps. Only one employee, though, was needed to actuate the opening of the clamps. As the machine ran, the two operators would place a sheet of plastic onto the wheel. Then each of the employees would go to his side of the station to actuate his set of two-hand controls. That operation would cause four separate pneumatic clamps to hold the part down through the remaining stations. In this incident. The positioning of the controls notwithstanding, it was still possible for an operator to reach into a pinch point while the wheel was cycling. In this instance, the employee had placed a part onto his side of the wheel without noticing that the clamp closest to him had not actuated. That clamp went through the entire cycle in an open position. When the clamp returned to the operator station, the employee believed that the other operator had opened the clamps. When the employee went to remove the part, believing that the other operator had opened the clamps, he inadvertently bumped the open clamp. It lowered unexpectedly, pinching eight of his fingers, all four fingers on each hand. The clamp was run by a pressurized air supply at approximately 100 psi (690 kPa). The employee was hospitalized. On January 10, 2022, three of his fingers were surgically amputated. The firm was fully aware of the ongoing issue. It was common for the operators to use their hands or a piece of lumber or steel bar to knock down the stuck clamps. Another operator had been struck by clamps approximately two weeks before this incident. That incident had happened on the number 10 thermoforming wheel.