Abstract: At 3:00 a.m. on December 21, 2020, Employee #1, an English-speaking female employee was operating the OB7 single-stroke pneumatic press, which presses bushings and rivets together. Due to unclear circumstances and the inability to speak with the employee, it appears that one of the two hand-control buttons was bypassed, allowing the press to operate with both hands. According to video footage, the press cycled while the employee's right hand was inside, resulting in a partial amputation of the tip her right thumb. Employee #1 was treated without hospitalization. The two-hand control system had inadequate protection, as it could be bypassed, allowing this incident to occur.