Abstract: At 10:30 a.m. on August 21, 2001, Employee #1, a die cast operator, sustained a crush injury to his left hand as a result of an accident. Employee #1 was working by himself on the Number 3 hydraulic die casting machine, built by Harvill, also known as "the hot chamber" to the employees who manufactured die casting products. The accident occurred at the die cast area where there were a total of four hot chambers on the production floor. Employee #1 was doing his normal routine work, using pliers to remove finish products from the point of operation with his left hand while spraying coolant onto the molding area to reduce temperature with his right hand. The mold closes when a green control button is pressed and opens by itself when the finish products are ejected from the mold. Coolant needs to be sprayed onto the molding surface to reduce the temperature so that the finish products will not be stuck. Employee #1 is right handed, and he uses his left hand to remove the end products so he can use his right hand to apply coolant. The pliers he used to remove parts were purchased by Employee #1, because the employer did not provide extension tools for employees to use. The handle of the pliers measures five inches long and it is a regular set of pliers like everyone uses at home, not a special extension tool, which would be a more appropriate and safer alternative. "I don't usually work on this machine" Employee #1 said during the interview, "I usually work on machine Number 4." The company admitted that they had not established nor implemented lock out and tag out procedures when work is being done while the machines are in motion. The company did issue locks to service personnel when repair work is scheduled, and everyone would share a same lock. It is a common work practice here to unjam a stuck part with a tool or to remove a finished product when it is ejected from the mold while the machine is running, according to statements from the president of the company and several employees during interviews. Cal/OSHA has determined that the accident was caused by a latch that was broken off inside of the interlocking mechanism, which allowed the circuit limit switch to be activated while the sliding door was still open. The employer admitted the broken latch was soon repaired after the accident to ensure that the interlocking safety device would function the way it should. The direct supervisor of Employee #1 was nearby when the accident occurred, but no one saw what happened. When asked during the interview, Employee #1 was not able to explain how the green control button was activated. Following the accident, Emergency Medical Services was called and paramedics responded. Employee #1 was taken to County USC Medical Center and later underwent surgery to repair the injury. All five of Employee #1's left hand fingers plus part of his palm were amputated as the result of the accident.