Abstract: On August 16, 2004, Employee #1 was working for a corn tortilla manufacturer as a Machine Operator located in the back production area. The sheeter head flattens the tortilla dough, which is then cut into uniform shapes. The sheeter head is made by Hacienda Precision. The motor used on it is a Baldor Industrial Motor, Serial Number F1084, 2 HP, 1725 RPM (for motor), and 3-phase. One of the duties of a Machine Operator is to change out the wire on the sheeter head that regulates the form, quality, and thickness of the tortillas. To replace the wire, the sheeter head is moved to the off position by a clutch handle. The clutch handle moves sideways a distance of about one- inch from the "on" to "off" position. Employee #1 was changing out the wire on the sheeter head on oven machine #1. He moved the clutch to the "off" position, but did not deenergize the machine. Employee #1 then opened the metal housing compartment on the side of the sheeter head and gained access to the gears to change the wire. The clutch was then bumped to the "on" position by Employee #1 while changing the wire (the clutch and the area where the wire is changed out is about six-inches apart), and Employee #1's left hand got caught in the gears. Employee #1 suffered amputation of the left middle finger to the second-joint.