Abstract: Employee #1 was a press operator for Los Angeles Die Casting. At the end of his shift he was cleaning the die area of a hydraulic press used to trim zinc parts of flash left from die casting. While blowing off the die area, he accidentally rocked back the left handle, actuating the press. The ram came down on his right hand, lacerating his index finger and thumb. The employer had added 1 1/2 in. steel blocks or bars, with attached handles, that rocked back to actuate the two-hand controls for the press. Unlike conventional palm buttons with ring guards, these handles could not be protected from unintended operation. In addition, the control circuit did not require concurrent pressure on these buttons to trigger movement of the ram. One handle or block was out of adjustment and had been left tipped back, depressing the right palm button. This resulted in the ram coming down when Employee #1 rocked back the left handle.