Abstract: Employee #1, a setup mechanic, was attempting to unjam a thermal forming machine. He hit the wrong button to stop the machine's trim form press portion. He then proceeded to open an interlock sliding barrier guard and reach into the point of operation. The machine, which was still activated, cycled and amputated Employee #1's left hand. The interlock on the guard had been bypassed. The machine's manufacturer and the company's policy state that the machine should be locked out in such situations. The employee had not been trained in lockout procedures, but also did not use other safety devices the company provided.