Abstract: At approximately 5:15 a.m. on December 7, 1994, Employee #1, of Cal-Compact Foods, Santa Maria, CA, and a coworker were operating an A-200 Packing Machine, manufactured by CVP Systems Inc. The machine, which was equipped with a two-hand safety device intended for one-man operation, vacuums air out of large plastic bags and then heat seals them. The machine had been malfunctioning during most of the employees' operation. The coworker pushed two buttons to seal a bag, thinking Employee #1's hands were out of the way; however, his right hand was in the machine's jaw and his thumb and three fingers were severely burned. Several coworkers tried to release the jaws by pushing the red emergency button, but it was inoperable. It took five minutes to free Employee #1's hand from the jaws of the machine. He was transported to the hospital and released three hours later; skin grafts were performed on December 29, 1994. The supervisor was aware that two employees were operating the machine.