Abstract: On December 2, 2013, Employee #1, with Astro-Tek Industries Inc., was setting up cutting tools on a mill, manufactured by YMT Inc. (CNC mill; Model Number: QV179; Serial Number: 1P01224D8). Cutting tools were to be installed on a spindle above the work piece, held on a moveable bed inside the machine. During the setup operations, the position of this bed and the spindle were to be controlled manually by buttons on the control panel, marked X, Y, and Z. While installing the tool on the spindle, Employee #1 had to step into the enclosure of the machine. While his left foot was inside the enclosure of the machine, he accidentally pushed a button on the control panel, which moved the work piece bed horizontally and pinned his foot in between the bed and the enclosure of the machine. Employee #1 suffered an open fracture to his left ankle. Surgery was performed to repair the damage, and he was hospitalized for two days.