Abstract: On December 20, 2012, Employee #1, with Beauty & Health International Inc., was observing the Resina Screw Capper machine (Serial Number 79-5798, Model U40-701) as plastic bottles (100 tablet count size) containing vitamins were being processed through the machine. Employee #1 saw one of the bottles tip over on the conveyor causing its contents to spill and creating a jam inside the machine. Employee #1 reached in through the discharge end to upright the bottle when the sleeve of her lab coat got caught in the chain and sprocket drive of one of the two internal bottle gripper belts. Employee #1's three fingers were pulled into the pinch point between the moving chain and sprocket that drives the gripper belt. The emergency stop was located directly in front of the employee; however, Employee #1 did not stop the machine before reaching in because she said she didn't think to do so that at the time. Employee #1 was transported to the hospital, where she was admitted for surgery. Her severed fingers were not reattached. Employee #1 had operated the Resina Screw Capper machine nearly on a daily basis and had received extensive training on lockout/tagout procedures that were required for cleaning and disinfecting the machine between batches.