Abstract: At approximately 11:00 a.m. on February 8, 2017, an employee was working at a manufacturing facility that specialized in the forming of tool molds from extruded plastics and resins for various industries. The employee started his shift at 5:00 a.m. and was assigned to operate one of the facility's vacuum thermo-forming machines. After returning from a break at approximately 10:00 a.m., the employee started the machine's cycle and soon noticed a hose hanging from the top of the machine. The employee climbed onto the fence of the machine to reach the hose for removal. However, as the employee reached for the hose, the platen part of the machine moved and pinned his head between the platen and the frame of the machine. A coworker that was working at another machine about 50 feet away observed the employee hanging from the machine and came to his aid. The machine was stopped and emergency services were contacted. Upon arrival, the employee was taken to a nearby hospital, where he underwent surgery to repair a lower jaw fracture, lacerations to the back of his head and the loss of four teeth. The incident investigation revealed that the employee had not been effectively trained on the safe operation of the equipment.