Abstract: On November 24, 2001, Employee #1, a lead person in training, was instructed to set up a Tiromat pocket forming machine for operation. He asked a coworker to operate the controls so he could feed film into the other side of the machine. Employee #1 instructed the coworker to turn on the machine, but changed his mind when he noticed the film was jamming in the machine. He then told the coworker not to turn it on; however the coworker did not hear this instruction. Employee # 1 had his arm between the dies when the coworker turned the machine on. He was hospitalized with arm fractures and second-degree burns. The cause of the accident was failure to lock out the machine or to use a tool to pull out the jammed film.