Abstract: On June 25, 1992, Employee #1, a toolroom machinist, was making adjustments on a cut-out machine that was equipped with two hand controls. Employee #1 had been in training under the usual set-up person for several months and was filling in for that person, who was on vacation. Employee #1 turned off the machine. Although the machine was equipped with limit switches, he did not follow the required lockout procedures. Employee #1 was making an adjustment when the limit switch malfunctioned and the cutter head came down on his hand. He suffered deep lacerations to the left middle finger, with an open fracture, and was transported to Queen of the Valley Hospital in West Covina, CA.