Abstract: On November 1, 2006, Employee #1 was working for Square-H Brands Inc., a company processing various types of meat products, including sausages and hot dogs. Employee #1 was notified by a machine operator that one of the Tiromat packing machines was malfunctioning. The operating pressure was too low, producing poorly sealed food packages. Employee #1 fixed the problem by hand adjusting a lever located underneath the machine. Employee #1 received a phone call about 30 minutes later stating that the problem returned. Employee #1 hand adjusted the lever, as before, by crawling underneath the machine. This time, Employee #1's left hand became caught by the machine's moving parts. Employee #1 was taken to the U.S. Health Works by a coworker and was later referred to Western Hand Center. Employee #1 underwent surgery to repair the wound. An investigation determined that Employee #1 attempted to time the packing cycles, and that he hand adjusted a lever he believed to be the cause of the problem. In accordance with the company's lockout safety procedures, Employee #1 did not implement them.