Abstract: At approximately 4:30 p.m. on December 3, 1990, Employee #1 was installing an elevator in a production plant. He was using a 3/8 in. Summit shear machine, model S2218, to cut some metal. As he was pushing the metal into the machine, his left index and middle fingers were amputated. He was attended by Los Angeles County paramedics, and then transported to the emergency room for treatment. Subsequent investigation revealed that the Summit shear was not adequately guarded and allowed access to the nip point: the guard was at a 150 degree angle and was not positioned correctly. The employer failed to maintain effective accident prevention and had other serious violations in addition to guarding. The employer also failed to report a serious industrial injury to the DOSH District Office.