The circumstances were:
- The machine was a depositor, which pipes liquid chocolate into moulds
- It was only partially guarded
- There was an interlocking guard at the top of the stirrer cavity but there was no protective device in place at the bottom.
- This meant that it was possible to reach in through the bottom even though the machine was running
- Joao Countinho was cleaning the machine on 29 February 2012.
- He had removed the rotors and reached up to check the stirrer cavity was clean but the stirrers were still rotating.
- His left index finger became trapped and was partially severed. It had to be fully amputated later in hospital.