Abstract: On May 11, 2000, Employee #1, a dough mixer at a noodle manufacturing plant, was working on a horizontal dough mixer. The machine had a mesh guard that was interlocked, and would stop the intermittently rotating blade, but there was another access point under the machine that, although guarded, was not interlocked. The mixer was forming balls of dough that would not pass through the lower opening, and Employee #1, instead of opening the upper guard, decided to try the lower access point. He removed the lower guard and was reaching up inside the mixer when the blade activated. Employee #1's wrist and hand sustained severe injuries, and his hand had to be surgically amputated. Although originally hired as a dough mixer, he had been recently working in other departments before returning to operate the dough mixer.