Abstract: On May 5, 2003, three men were working in a plastic bag manufacturing plant at a Flexographic Printing Machine. Due to the size of the machine, the three employees could not see each other at all times. The workers were readjusting the machine to accommodate a different size of bag. Specifically, Employee #1 was adjusting impression gear. The machine operator asked the lead man if he could start the machine, and the lead man said yes, he could. The operator started the machine and the gears drew Employee #1's left hand into the gears which amputated part of his index finger and all of his middle, ring and little fingers of that hand. Employee #1 was transported and admitted to the Western Hand Center. The Flexographic machine was not stopped and the power source not deenergized or disengaged, and the moveable parts were not mechanically blocked or locked out to prevent inadvertent movement during adjusting operations. The company's lockout procedure involved putting a warning tag on top of the controls. No positive means of locking out or blocking out the controls was required. The employer had no lockout procedures specific to the Flexographic Printing Machines and had not performed an annual review of the lockout procedures. No extension tools were provided for adjusting the gears while the machine was in operation.