Abstract: At approximately 11:50 p.m. on November 7, 1995, Employee #1, one of two press operators on a Newbury 30-ton vertical shuttle hydraulic press, noticed that one of several tiny brass pins set into the lower die was not straight. During a four-second time window in which a 4 in. space opens up between the side guard and the lower die impact zone, Employee #1 reached her right hand into the die impact zone to straighten the pin. The other press operator activated the two hand concurrent control buttons and initiated a cycle. The ram lowered in low pressure mode and struck the first phalanges of all four of Employee #1's fingers. Her fingers stopped the ram from proceeding into high pressure impact, enabling coworkers and maintenance employees to manually raise the ram and die and release Employee #1's hand, which was severely scalded on the back by heat from the molds. Management had made this a two-person operation to increase production, not taking into account the lack of protection for the second operator's hands. Management had also not noticed the 4 in. gap created during the shuttle slide of the lower die. The manufacturer's frontal interlock Lexan guard and both side guards were intact and properly set. The addition of the second party immediately created new hazards unforeseen by the company's management.