Abstract: At approximately 7:30 a.m. on January 23, 1998, Employee #1, a trainee with twelve days of experience at a burn table, was transferred to learn how to operate a 520 ton Cincinnati part-revolution press brake, serial #24683. The machine, which bumps/tamps 96 in. long by 1 1/4 in. wide machine parts into a channel using two flat-faced dies, was demonstrated by a trainer, who also ran several parts. Employee #1 then ran 12 parts while the trainer went to an adjoining roller machine but kept his eye on the trainee. After bumping approximately 150 parts, Employee #1 continued to depress the foot pedal when he reached into the point of operation for a finished part. The press brake cycled and fractured the four fingers on each hand, with the exception of his thumbs, between the flat dies. The first two phalanges on his left ring finger and right index finger were later amputated. A series of four, two-hand concurrent control buttons across the ram above the point of operation were not working, and activation was by a moveable electric foot pedal designed to continue the cycles as long as the pedal is held down. There was no other form of guarding and Employee #1 was not properly supervised.