Abstract: On February 13, 2006, Employee #1 was assisting a coworker in running Packline packaging equipment, Model Number PXU-4, Serial Number PL710017, that filled container cups with food material such as dips, place lids on the cups, seal them, label them, and coded them for retail sale. The employer ran a manufacturing facility that cut, mixed, baked, and packaged food. Employee # 1 was tasked to ensure that the machine had enough cups and lids, so that when the cups passed a designated location, the lids were placed on top of the cups and then sealed with a roller. Also, on occasion, when the machine would become jammed and food material would spill, Employee #1 was required to unjam the machine and clean any stuck material. The packaging equipment was covered with plexiglass and its access doors had interlocked mechanisms except for where the lids of the cups were loaded into a column. An Emergency-stop button that stopped both the electrical and pneumatic energy source of the machine, was also located on the machine. As Employee #1 was standing on a 24-inch high platform in front of the lid section of the machine, she observed a lid on land one that was not properly seated on a cup. She pressed the Emergency-stop button and reached into retrieve the misaligned lid. However, the machine inched forward and her left index finger became caught between the roller that would push the lid tight on the lip of the cup and the lid. She then tried to remove the lid with her right hand, but the machine moved forward again, further pulling her left index finger under the roller, which was amputated. The accident investigation revealed that the employer had been having problems with the alignment of the lids on the cup.