Abstract: At approximately 7:00 p.m. on April 26, 1996, Employee #1, age 20, was operating a P12 press, used to manufacture heater parts, in continuous mode. At some point during the operation a finished part became stuck in the machine and failed to fall into the basket below it. The P12 press was equipped with double hand and foot pressure pad operating points; to operate in continuous mode, these pads had to be overridden by a supervisor with a "501" key setup. The press was also guarded by an electric curtain system that was placed in front of it, and equipped with an EMERGENCY STOP button on the control panel adjacent to the double hand pads. Both the electric curtain and the EMERGENCY button stopped the press through braking; and once braked, the press could not be restarted without realigning it and getting a key from the supervisor. There was, in addition, a PROCESS STOP button on the press itself, which allowed the press to stop and be restarted without the key, so long as the hand and foot pads were depressed. There were no witnesses to what transpired after the finished part became caught in the press. According to Employee #1, he hit the PROCESS STOP button, and then reached through the electric curtain and into the point of operation, hoping to retrieve the lost part. While his hand was in the point of operation, the machine cycled once more, lowered onto his fingers, and amputated them below the knuckle joint. He freed his hand from the press and went to his supervisor, who called emergency services. At the time this report was written, there were conflicting reports about the manner in which Employee #1 had shut down the press.