Abstract: At approximately 5:30 p.m. on September 21, 1993, Employee #1, a journeyman maintenance mechanic for Beatrice Cheese, was injured while working on a vacuum packaging machine. Employee #1 was working on the equipment with another employee. Employee #1 was attempting to adjust the electric eye that controls the depth at which the mold descends into the die. Both employees stated that the machine must be running to make the adjustment. After the adjustment is made, the machine should be turned off, loaded with plastic film, and operated until several casings are formed. After several casings have been made, they should be checked to see if the mold is descending into the die at the proper depth. Employee #1 checked the depth by sticking his hand into the area where the die and mold come together and placing his hand on the mold housing to feel if the die strikes the bottom of the mold. While he was attempting to touch the side of the mold, his hand entered the area where the die and mold mate. He sustained partial amputation of two fingers on his left hand. The cause of the accident was that Employee #1 was not following establishment procedures. The employer has an energy control procedure, and Employee #1 acknowledged awareness of the procedure. Employee #1 has been employed by Beatrice Cheese for 17 years and works on this machine and similar equipment almost exclusively. Employee #1 had received specialized training on the equipment through the manufacturer.