Abstract: At approximately 9:15 a.m. on July 15, 2004, Employee #1, a cook, was ordered to run a 9-Plate Colborne rotary pie shell machine, Inventory Number 33, in the Pie Processing Area because two other employees who usually ran the machine did not come to work that day. Employee #1 had no training on the machine and an operator's manual was not available. The machine has a guard which does not adjust and is set to accept a wad of dough to roll out into a pie shell. Trained employees push the dough toward the roller with the side or palm of their hand to avoid entrapment. No extension tool was available. Employee #1 with no training pushed the dough into the roller with his fingers, and the machine took his whole hand into the roller. Employee #1 hit the stop button with his left hand but it did not protrude beyond its metal sheath and did not stop. Coworkers stopped the machine and dismantled the roller. Employee #1 suffered multiple broken bones in the right hand and nerve damage. Employee #1 suffered permanent mutilation of the right hand with limited hand function. Employee #1 was hospitalized.