Abstract: Employee #1 was operating a Buhler hydraulic trim press in the main plant. The machine trimmed excessive aluminum from cylinder heads that were being manufactured, and then a slide carried the parts to a large wire basket. Employee #1 was standing to the left of the point of operation, showing the quality control manager a hydraulic oil leak on the unguarded slide. She pointed her finger at the leak and then looked away to speak to the manager. The slide was being pulled back toward the machine, and it caught Employee #1's right hand and pulled it into the machine. Employee #1 could not reach the EMERGENCY STOP button, and nearby coworkers did not know where it was. Employee #1's hand was so badly mangled that surgery was required to amputate her index finger and thumb, and the central portion of her palm.