Abstract: At approximately 11:00 a.m. on March 12, 2004, Employee #1, a machine operator, was involved in a tooling change (when it was necessary to change the part being manufactured) on a swaging machine (manufactured by American Machine & Hydraulics of Newbury Park; the machine did not have any model nor serial numbers) located in the fabrication department. The machine had the capability of increasing the internal diameter of short length hollow pipes. The machine panel (away from the operator) consisted of a top button (with two settings: auto and set up), the lower middle green button started the motor and pump machine, and the lowermost red button stopped the pump machine and motor, but the electric circuit would remain energized. By the operator's position there was an emergency switch which disabled both the pump machine and motor and the electric circuit. During set-up, the machine would be set to set-up mode and during productions cycle the machine would be put in auto mode. During set-up, the left-hand side or right-hand side palm-push buttons (approximately 3.5 ft apart) would advance the tool set up to the left and right, respectively. During auto mode the two push-buttons would be activated simultaneously whereby the tool moves from right to left (maximum travel approximately 2 ft), enters part length of the pipe (internal) diameter and reverses and withdraws when the limit switch is contacted. Employee #1 inadvertently touched or hit the left hand side palm push button which resulted in the trapping and amputation of his fingers by the tooling being changed as the tool advanced from right to left. The employer did not have a lockout or tagout procedure for the swaging machine during set-up and adjusting operations involved during tooling change. According to Employee #1, he was in the set up mode, setting up the tooling, when suddenly the machine tooling jammed due to a malfunction. Employee #1's fingers were trapped as the tooling plunger moved from right to left. This caused amputation of Employee #1's index and middle fingers of the right hand. Employee #1 was hospitalized.