Abstract: At approximately 8:15 a.m. on June 1, 1994, Employee #1, a machinist for the City & County of San Francisco's Department of Parking and Traffic, had been working for a couple of days making keys with a punch press. During that time, the press had jammed twice and had been unjammed by a coworker. Also during that time, the two-hand trip occasionally had not cycled when it was activated. Employee #1 visually inspected the press before operating it, then continued to work on the second phase of his project. He flattened the first key and as he reached in to remove it, he heard a noise. He looked around, then at the key, and saw that his fingertip had been crushed by the ram, which had descended again. He was taken to San Francisco General Hospital where his right index finger was amputated at the second knuckle.