Abstract: On January 4, 1997, Employee #1 and a coworker were operating the #6 cup machine, which formed cold drink cups and cartons. While they were setting up and troubleshooting, the coworker was on the control side of the machine and the unit was in jog mode. Employee #1 was at the non-operator (opposite) side of the machine, retrieving blanks during the set up. He did not use the primary or secondary safety switches or the emergency stop before reaching into the mandrel area of the machine to retrieve a burnt blank. The unit had been jogged by the operator, who did not realize that Employee #1 had gone back to that part of the machine. Employee #1's left hand was injured when it became caught between the mandrel and the bottom finishing station of the machine. Set up and troubleshooting for the cup machine was usually a one-person operation.