Abstract: On January 19, 2005, Employee #1 was working in the lamination department on a Scott Ten Thousand Automatic Plastic Index Tab Machine, Machine Number 9. This machine takes sheets of paper with preprinted tabs for filing purposes and attaches a colored piece of Mylar, plastic colored strips, on the preprinted tabs. The machine uses heat to seal the Mylar to the tabs, and then the tab is colored with the Mylar attached to it. Employee #1 noticed that the cut being made by the machine was not in the correct place. She needed to adjust the reregister wheel to align the machine with the paper to make a more proper cut. She did not turn off the machine before adjusting the lever to move the reregister wheel. The guard that was covering the blades could be lifted. The blades were 0.5 in. away from the end of the guard and there was a 0.75-in. opening where Employee #1's finger could slip under the guard. Employee #1's finger went underneath the guard and was exposed to the cutting blade in motion. Employee #1 received a complete amputation of the third finger tip, a fourth fingertip avulsion, and a fracture of the third finger.