Abstract: On April 17, 2003, Employee #1 was fixing a spinach pump at Pictsweet Frozen Foods in Santa Maria, California. The spinach pump was not working correctly and had been turned off. The employee took off the guard for the two 0.75 in. V-belts, and as he was checking the V-belts, another coworker turned on the motor. The coworker thought he had been instructed to do so. The switch to the motor was 4 ft away from the V-belts and the coworker was not looking in the direction of Employee #1 when the motor was turned on. Employee #1's right ring finger was caught between the pulley and the V-belts. His ring finger was amputated to the first joint and he suffered injuries to his middle and index fingers. Employee #1 was hospitalized. The employee had a lock and key on him and had been trained to lockout, tagout but did not use the key because of his closeness to the switch.