Abstract: At approximately 9:50 a.m. on April 2, 1998, Employee #1 was operating a pneumatically controlled, foot-operated 60 ton, full revolution E. W. Bliss punch press. He was fabricating aluminum shingles when the press inadvertently cycled, catching Employee #1's left hand in the die, and then continued cycling even after the OFF button was pushed. He sustained injuries to his hands and fingers, but did not require hospitalization. Employee #1 was wearing pull-back devices at the time of the accident, but they were not adjusted to fit him properly. He had never been instructed on how to adjust the devices and had never been told to adjust them, only that he would be fired if he failed to wear them. Employee #1 spoke only Spanish; the coworker who trained him did not speak any Spanish.