Abstract: At approximately 2:04 p.m. on February 6, 2008, Employee #1, a senior production worker employed by a machine tool accessory manufacturing company, was working on a new product prototype. Employee #1, who reported directly to the plant manager and the company president, had 18 years' experience with the company plus prior experience as an aircraft sheet metal specialist in the United States Air Force and six years' experience as a general machinist/tool and die maker with other employers. Employee #1 removed a safety guard during a sample production run to make an adjustment. He inadvertently activated a clamping unit, which caught the tip of his right index finger. Emergency services were called, the San Francisco Fire Department arrived at approximately 4:30 p.m., and emergency medical personnel began to treat Employee #1. He then was transported to Davies Hospital for further treatment. After 7 hours at the hospital, Employee #1 was discharged. On February 11, 2008, without alerting the employer, Employee #1 went back to Davies Hospital for further treatment. The physician was unable to save the tip of his right index finger and amputated it. This event was investigated by Cal/OSHA, which completed its investigation on April 2, 2008. It determined that the serious injury was caused by violation of safety orders as set forth in Title 8 California Code of Regulation Section 3314(c)(1) Cleaning, Repairing, Servicing and Adjusting prime Movers, Machinery and equipment. The classification of the violation was general rather than serious because the employer did not have knowledge that the machine was not deenergized while the adjustment was made. Employee #1 had training on lock-out/tag-out procedures and machine guarding.