Abstract: On April 8, 2008, an employee was working as the operator of a packaging line for Interpac Technologies, Inc., a wholesale distributor of groceries, in Woodland, CA. On his line, pouches were to be filled. He noticed that the pouches had become bunched up by a knife that was supposed to cut the pouches apart from each other on the filling line. He hit a STOP button on the line's computer screen, thinking that action would stop the line. When he reached into the line to pull the pouches out, the line cycled and the knife activated, amputating two of his fingers. A coworker offered assistance and cut the power to the line. The Woodland Fire Department responded and arranged transportation to UC Davis Medical Center in Sacramento. The employee sustained amputations to his right ring and middle fingers. A clear enclosure surrounded the packaging line, and individual doors with interlock safety controls allowed access to various parts of the line. The interlock devices were not operational and the actual doors physically removed at the time of the accident.