an employee maintenance fitter was performing maintenance on a Magnuson Brush Washing
Machine. At the time the machine was not effectively isolated. . There was general confusion between the
maintenance staff regarding the functions of the various switches on this multiple‐drive motor machine. There
was no specific lockout procedure and the generic lockout procedures had not been followed.
The employees involved had no specific training in any isolation procedures. The employee's left thumb was
amputated when the machine started whilst he was working on it.