Abstract: On September 1, 1999, Employee #1, a fruit feeder on line 14 of Nestle Ice Cream Company, was working at the feeder machine. She was required to clear excess product from the auger at approximate 15 minute intervals. The company procedure was to shut the machine down with the manual "E" stop switch, remove the guard, clear the product, replace the guard, and then restart the equipment. Employee #1 thought she had shut the equipment off and used her hand to clear the product. Her fingers were caught in the auger and were amputated. The machine had not been deenergized for this operation. She was taken to Mercy Hospital for emergency treatment and was hospitalized.