Abstract: Around 1:00 p.m. on June 18, 1998, Employee #1, a machine shop supervisor at an iron foundry, had finished working for the day. On his way out, he stopped to help his replacement change the bottom die of the turret on a vertical-tapping machine. Employee #1 had trained a replacement in preparation that day. Although the practiced procedure called for turning off the ram switch (not the main power switch), Employee #1 did not inquire if the machine had been de-energized. He attempted to tighten the tool manually when he saw that the turret moved and trap his finger between the ram and the work surface. Employee #1's left ring finger was amputated and collected on ice. Employee #1 was hospitalized, where he received treatment. There was no written procedure for changing the turret and bottom die. Employee #1was the only employee allowed to perform this operation. No lock-out-tag-out procedure had been followed, except for maintenance.