Abstract: On August 17, 2010, Employee #1 was working for Pace Lithographers, Inc., a commercial printing business that had been operating for about 35 years, in City of Industry, CA. It had about 42 employees on its payroll. Employee #1 had been employed about 32 years as a lithographer and manager. He was servicing a chiller unit located on a sub-roof inside a building. He had opened the panel cover of the chiller unit himself for the task. Although deenergizing the unit was required by regulation, he had not disconnected the 220-volt power supply to the chiller unit. The fan inside the chiller unit was running. Employee #1 was pouring some coolant into the tank of the refrigeration system located inside the chiller unit, when the fingers on his left hand contacted the moving blade inside the unit. The index finger on his left hand was fully amputated, and he sustained a cut to the tip of his left thumb. He was hospitalized for three days in the UC Irvine Medical Center for treatment. Investigations revealed that power lockout-tagout safety rules were not followed during servicing of the chiller unit, and the employer was subsequently cited for this violation.