Abstract: On June 17, 2011, Employee #1, a machine operator, was training another employee on sanitation procedures for a dumpling machine (Tosei Kogyo Co., Ltd., Japan, Model Number A-16NA) in the production area of a Shine Food, Inc. A sheet of plastic had been placed around the cutter box to protect its components from water during the cleaning process. The machine was on and running at slow speed while the trainee washed part of it with a pressure washer. When Employee #1 observed the plastic being drawn into the cutter box, he knelt down adjacent the discharge end to reposition the plastic. He lost his footing and inadvertently placed his left hand on the bottom plate. The tips of Employee #1's third and fourth fingers were amputated by the form cutters inside the box when they cycled. He was hospitalized for treatment. A conveyor that circulates the dough through the machine during production and served as a guard for discharge opening had been removed prior to the cleaning. This exposed the discharge end of the cutter box where the form cutters were 1.25 in. away from the edge of the 0.75-in. opening.