Abstract: At approximately 8:25 a.m. on April 24, 2000, Employee #1, an inmate at a state correctional facility, was in the milk processing facility where he worked on a regular basis. He was removing a damaged 1/2 pint carton that had become stuck on a rotating mandrel arm of the PPI-Shikoku Pure-Pak milk packaging machine, model UP-M160, when his left arm became caught. Employee #1 sustained serious lacerations to his forearm, for which he was hospitalized. He had not been trained in lockout/tagout procedures, and had not stopped the machine before trying to remove the carton. The interlock safety switch on the panel door of the mandrel assembly had been disabled by someone a considerable time before the accident.