Abstract: At 5:54 a.m. on January 6, 2021, Employee #1, employed at a manufacturing facility, was operating a Beckwood Hydraulic Press (Model Number 4P20F4050-2, Serial Number 315531) in the press room of a single-story factory building. Standing outside the 85-inch by 44-inch safety mat intended to protect employees, the employee reached into the point of operation to adjust a plastic cover on the press with his right hand while supporting himself with his left hand. This adjustment was routinely performed by employees to prevent the product from sticking to the mold. The press cycled unexpectedly, amputating Employee #1's left thumb at the metacarpophalangeal joint. The employee was hospitalized for treatment. Employee statements revealed that the safety mat was unreliable and the press would occasionally cycle even when employees stood on the mat. Several employees worked in the unheated, dry press room at the time of the incident.