Abstract: At approximately 6:00 p.m. on February 3, 1995, Employee #1 was working at the Division 9 fruit processing facility. He was a trained and experienced worker in charge of the decanter, finisher, mash tanks, peel tanks, reitz press, cattle feed augers, and secondary finisher. Maintenance had finished repairing the cattle feed incline auger and, following a dry run, permission was given to start it up. At approximately 6:45 p.m., Employee #1 activated the auger to run peel (product residue) into the truck. The supervisor noted peel all over the ground at the bottom of the auger, and Employee #1 and a coworker attempted to clean up the mess coming out of the auger's washout opening. Employee #1 reached into the washout opening while the auger was running instead of having it turned off and locked out, as required and as he had been trained to do. The second, third, and fourth digits on his right hand were traumatized, the tip of the third digit was amputated, and his second and fourth digits suffered extensor tendon injuries. A coworker said Employee #1 was the only one who used his hands to check and clear product residue from the opening while it was running. Operators were issued lock keys and tags, and extra locks, keys, and tags were located in the power room and supervisor's office.