Abstract: At approximately 5:00 a.m. on May 19, 2007, Employee #1, a machine operator, was working alone, cleaning and changing the coolant on a CIN 2-24 Plain Automatic Mill. He was wearing work gloves and glasses. The mill was switched on and the coolant was being transferred into a bucket. As the coolant was being transferred, Employee #1 began cleaning the machine using a short handled brush. As he placed the brush down and reached for the bucket, his right hand was caught in the cutter of the machine, resulting in a near-amputation of his right wrist. Employee #1 was not using Lockout/Tagout procedures nor was the machine appropriately guarded. He had previously received general Lockout/Tagout training, but no training specific to the mill. Employee #1 was transported by his supervisor to a local clinic but was later transferred to County USC Medical Center. He underwent surgery and remained there for twenty-three days. .