Abstract: At approximately 6:15 p.m. on February 5, 2017, Employee #1, a case packer operator, was working on Line Number 2 located in a packaging department at a company that produces dairy proteins and nutritional products. He reached around the guarding on the case packer to inspect a guard plate on the conveyor tail end that had a history of becoming loose. As he was reaching to touch the guard plate his hand slipped causing two fingers to enter a pinch point immediately adjacent to the guard plate. The case packer and conveyor were not shut down and locked out prior to the troubleshooting, and machine guarding was inadequate to prevent the employee from accessing the pinch point. Employee #1's third and fourth digits on his left hand received avulsions and his fingertips were amputated at the hospital but was not hospitalized.