Abstract: Employee #1, the supervising chef, was using a small Hobart meat grinder to prepare shredded chicken for a special function. The process required the use of a specialized die with 3/4 in. holes, which is placed in front of the rotating blade at the extruding end of the grinder. After processing the chicken, a coworker cleaned out the grinder by running water through it, but failed to turn off the power as required by company safety rules. Employee #1 injured his right index finger when he stuck it into one of the die holes while trying to pull out a piece of chicken. He was the only person who used the 3/4 in. die, and the other dies had smaller openings through which a finger could not fit. Employee #1 stated he knew he was violating company safety policy by cleaning the grinder with the power on. His injury was caused by a non-routine event that was not present for other employees.