Abstract: On December 16, 1991, Employee #1, of H.B. Manufacturing Co., was assigned to flatten small aluminum pieces, approximately 1 in. by 1 in., using a 35-ton hydraulic power press brake. The unit was foot-pedal cycled and had a part revolution clutch. Employee #1 had used the press before but never on high speed; he had never received safety instruction, nor was he informed that the press was set on high speed. The foot pedal was unprotected and the point of operation was unguarded. Employee #1 cycled the press while both index fingers were between the flattening dies and both fingers were crushed. He was taken to Alta Bates Hospital, where both fingers were amputated to the first joint.