Abstract: Employee #1 was operating a hydraulic press that set metal studs into a bracket. He had to place his hands in the die on three occasions: to place the bracket in the die, to insert the studs into the bracket, and to remove the final part. The press was cycled with two-hand controls. Employee #1 was reaching into the point of operation to remove the final par when the press began to cycle without actuation of the two-hand control. The tip of Employee #1's thumb was amputated. Subsequent investigation revealed a malfunction in the time-delay relay in the press control. The press was not equipped with control reliability.