Abstract: At approximately 12:30 p.m. on July 16, 2011, Employee #1 was performing his duties as a production worker for a private, incorporated company, in Commerce, CA, that produced food flavorings and colors for wholesale distribution to the food service industry. Onsite activities included the use of horizontal mixers and blenders, grinding machines, and industrial trucks. Various ingredients were manually poured into mixing equipment, according to the customer's specifications. Apparently, the resulting product was then collected and packaged for distribution. At the time of the incident, Employee #1 was working in the powder department of the facility and was preparing to mix a batch of powdered flavorings in a Food Processing Equipment Company Model Number 814 Horizontal Mixer (Kettle Number16). As part of the company's quality control procedures, the mixers were swabbed for allergens, prior to product mixture. This procedure involved using a Hygiena Ultrasnap swab, measuring approximately 6 inches in length, to swab a 6-inch diameter, 8-inch length delivery pipe, located at the bottom of the mixing chamber. Although this procedure was usually conducted by quality control technicians, Employee #1 stated that he had swabbed mixers approximately five or six times prior to the incident, when requested to do so. On the day of the incident, a quality control technician asked Employee #1 to swab the mixer because the quality control technician had not brought his respirator. A respirator was required to enter the mixing room, and Employee #1 did have his respirator on and was already in the mixing room. With the mixer energized and running, Employee #1 reached into the delivery pipe, with the swab in his right hand. The ribbon mixing blade caught Employee #1's right hand and amputated it at the wrist. It also dislocated his right elbow. Employee #1 was hospitalized. Employee #1 stated that he did not realize the mixer was running because the motor was very quiet, when the machine is running. The quality control technician also stated that he did not realize the mixer was running until after the incident, when he observed that Employee #1 was injured and could see the reflection of the turning ribbon mixing blade on the open top of the machine. According to Employee #1, the quality control technician, the powder department supervisor, and other production workers, the mixers were not locked and tagged out when conducting the swabbing and cleaning operations; the power was only disengaged by depressing the stop button on the machine. Cal/OSHA determined that the incident was caused by the horizontal mixer not being properly deenergized and disengaged prior to the swabbing operation and issued an accident related citation to the employer.