Abstract: On April 6, 2002, Employee #1 was taking dough mix used to make tortillas, masa, out of a food mixer. Employee #1 was operating a horizontal dough mixer, in which, the employee pours the powdered mix into the mixer and then adds water. The mixer has a horizontal plunger; pushing the plunger in shuts the mixer off and pulling the plunger out, starts the mixer. Once the dough is mixed thoroughly, it is ready to be removed. The employee must push the plunger in and open the top and with both hands to remove the dough from the mixer paddles. Employee #1 had shut off the machine, opened the top and started to remove the dough; when the mixer suddenly started by itself. The machine was very old and had to be disassembled by the Fire Department to remove Employee #1's hand. Due to the dismantled state of the mixer at the time of inspection, the cause of the startup was undetermined. Employee #1's supervisor had seen the employee do this many times over the past year and even helped him remove the masa on different occasions. Employee #1 was hospitalized.