Abstract: On November 11, 1994, Employee #1 was told to operate a 600-ton Cincinnati press brake machine for the first time. He was taken to the machine by the foreman and asked to bend 100 pieces of steel plate, 1/4 in. by 6 in. by 2 to 3 ft, making a 10 degree bend. He was shown how to hold them with his left hand at the end near the die and his right hand at the rear end of the steel plate. Employee #1 did the task for approximately one hour, using a foot pedal. He was then told to help tie down a truck and when he got back he inserted another steel plate. The machine came down and the steel plate came up, pinning his left thumb between the die and the steel plate, cutting off his thumb above the first knuckle. He was hospitalized. Someone had reset the machine for an 80 degree bend. Employee #1 did not know the machine had been reset and so was holding the steel with his left hand in the wrong place.