Abstract: Employee #1, a relief filler operator at Nestle's Food Company, had 7 years of experience at the company, including 2 years as a relief operator and 3 years as a relief operator working with the frequency of a regular filler operator. Employee #1 was in the last phase of cleaning the #3 seamer by hand. Instead of de-energizing the equipment, disengaging the clutch, activating the wash cycle, pulling the driveshaft pin (this disengages the seamer from the filler), and placing the equipment in the jog mode, Employee #1 was cleaning the machine while it was running. Employee #1 was cleaning the machine with a scrub pad in his right hand while engaging and disengaging the clutch with his left hand--this action causes the rotating members of the seamer to start and stop. Using this method, the machine would continue in a full cycle and run continually until the clutch is disengaged. In the jog mode, the machine turns once and stops (actuating the clutch is not necessary). While cleaning the machine, Employee #1's right hand was pulled into the area of the equipment where there is a severe pinch point. He suffered partial amputation of his right thumb and index finger. The cause of the accident was Employee #1's failure to disengage the equipment prior to cleaning it. Employee #1 acknowledged that he was aware of the hazardous energy control policy and of the requirement to stop all equipment prior to cleaning, servicing, or maintenance. No member of the management was in a position to anticipate Employee #1's action or to have had first hand knowledge that a violation was committed. Employee #1 confirmed that no management personnel were in the area when he was hurt.