Abstract: At approximately 4:30 a.m. on March 3, 1992, Employee #1 was operating a quick die cutting press that cuts sheets of leather into patterns. The press was equipped with a two-hand button control. There were no witnesses, but the supervisor believed that Employee #1 removed his left hand from the left button and placed it between the top of the die and the bottom of the press head. He did so to adjust the die after he had depressed the two-hand buttons to have the press cycle, and pressed the press head on top of the clicker-die. As a result, Employee #1's left index finger was caught between the die and the press head and crushed in two places, one at the tip and one between the first and second joints. Employee #1 was hospitalized. According to the supervisor, Employee #1 had not followed the employer's safety rules, and had not kept his hands on the control buttons at all times. No defects were found on the equipment. The employer has a well devised safety program. Employee #1 caused a safety infraction that he knew was contrary to the employer's safety requirements.