Abstract: On April 1, 1997, Employee #1, age 20, was performing his normally assigned duties as a pasta maker in a restaurant. Water, flour, and eggs were emptied into a mixing chamber at the top of the pasta machine. Normally, the mixing chamber had a guard that allowed the machine to run when it was in position but would stop the machine when it was raised. Due to a design problem, the machine was also able to run when the guard was completely removed. At the time of the accident, Employee #1 was standing on an aluminum ladder and was reaching across the mixing chamber. The ladder moved, throwing Employee #1 forward into the moving blades of the machine. His left arm sustained serious injuries and was surgically amputated above the elbow. The aluminum ladder used for access was missing its nonskid feet and had two broken cross members on its back. The guard for the mixing chambers had been removed for repairs.