Abstract: At 12:35 p.m. on June 13, 2002, Employee #1, a temporary worker with Lewis Staffing, was cleaning a Formax hamburger patty making machine (serial Number A97111, Line 4). The built-in barrier type guards had to be removed prior to the cleaning operation. The last safety device to protect employee, the magnetic safety interlocks, were not functional. When the machine activated, Employee #1's thumb, first and second fingers on his right hand were amputated. The accident was caused by failure to train in and follow lock-out and tag-out procedures and by the machine's non-functional automatic safety switches.