Abstract: At 7:00 p.m. on December 15, 2005, Employee #1, a machine operator, was adjusting a part of the die on a Pak-Star machine, Model Number DXD-30A, used on a production line to package medicines and vitamins. The machine contains a packaging film that seals vitamin or herb powder into packets. Additionally, a Teflon tape is placed on the dies to prevent the film from sticking to the heated dies. On occasion, the film melts and sticks to the dies or the Teflon tape begins to lift or peel off the dies, which requires the machine operators to make adjustments. For these adjustments, a brush is used. While she was adjusting the machine's part, it was in the operation mode and no lockout device was installed. Also, instead of using the brush, which is provided by the employer, she used a paper towel to adjust the Teflon tape on the surface of the dies. Employee #1's right middle finger became caught between the dies on the machine and was amputated.