A male food production worker, 54, who a pizza dough manufacturing facility employed, sustained fatal injuries due to deep neck lacerations made by a steel blade on a dough machine. On the day of the incident, the victim and a co-worker were assigned to clean two dough machines, an “elevator” and a “divider”. The “elevator” had three major components: a lifting mechanism, a hopper, and a steel blade (“dough chunker”) that was located at the bottom of the hopper. The facility’s lockout/tagout procedure required an operator to set the control buttons of the “dough chunker” to “Off” and “Manu” before turning off the main power switches. Before the incident, the victim turned OFF and locked the power switches but left the “dough chunker” controls set to “On” and “Auto”.