Abstract: On July 21, 2008, Employee #1, a machine operator, was operating a 15-inch liquid pouch packaging machine at the Portion Pac, Inc. plant. The machine operates in automatic mode, and was engineered and manufactured by the employer at another facility they own. The machine has three types of operations: sealing, filling and cutting. Packets are formed when two rolls of material are sealed, then the machine injects the liquid (ketchup, mustard, mayonnaise, etc.) and the top of the packet is sealed and then cut. The machine has a plexiglass door which isolates the point of operation, but does not function as a true guard since the door has no interlock and the space between the point of operation is too wide. Employees can place their hand either over or under the cover to come within the zone of danger. Employee #1 was operating the machine when a packet got stuck because it didn't seal right. He opened the plexiglass door while the machine was still running and stuck his fingers/hand into the point of operation and suffered partial amputation of the fingers of his left hand due to the knife blade coming down to cut the packets. Employee #1 was hospitalized for treatment of his amputated fingers.