Abstract: At approximately 4:30 a.m. on April 20, 2005, Employee #1, working for a temporary employment agency, was sent to a sanitation department of a sugar packaging company. The sanitation department was responsible for cleaning and sanitizing the packaging machines. The machine was a 10-up packaging machine designed in house. Employee #1's agency did not ensure he was properly trained on the equipment he was to clean, conduct a safety inspection to identify unsafe work practices, train him on lock out tag out procedures, nor ensure that the company had hazardous energy control procedures in place. Employee #1 was cleaning the machine next to window number 9, which was not deenergized. He was cleaning the in running side of rollers when his rag was caught in the roll while the machine was being jogged. His finger was pulled in and he received a partial finger tip amputation with bone loss.