Abstract: At approximately 11:45 a.m. on October 24, 2003, Employee #1, a machinist, was working for Concrete Molds Component in the mill department. Concrete Molds Component is a manufacturer of steel molds for concrete mold forms. The employee was making a sidebar part on the Cincinnati vertical mill machine. He had just removed the rough cutting cutter head and was in the process of installing the fine cut cutter head, a 4-inch indexible cutter head. He held the cutter head in his left hand and had lowered the spindle head partially to the cutter head he was holding. He then reached up with his right hand to press the draw bar switch, and as he was doing this, his leg pushed into the spindle activation lever located at 2.5 ft off of the floor on his left side. The spindle came down on the cutter and his hand which was holding the cutter palm up. The employee stated that he was in a hurry and forgot to put the spindle engagement lever in neutral. The employee suffered an amputation of his left middle finger, partial amputation of his left ring finger, and multiple fracture of his left index finger. After the accident occurred, he was taken to US Healthworks, where the doctor stabilized him and he was transferred to the Western Hand Center, where surgery was performed. Employee was not hospitalized. There was no written procedure for the machine set up of the vertical mill, no lockout/tagout program on site, nor any training records for the employee on the set up procedure for the vertical mill equipment.