Abstract: At approximately 0:01 a.m. on December 29, 2008, a machine operator at Sun Maid Growers of California, was cleaning a material jam from an Eliot box folding machine. The machine was not locked out. When the material transport system started to operate, the worker's left middle finger was severed, by the shearing action of the "feed dog." Removal of the jammed box was performed without deenergizing or effectively locking out the machine. The employer did not perform a hazard analysis on the machine, which had been in service for ten years. In addition, operator training was insufficient, and machine specific lockout/tagout procedures were not developed.