Abstract: At approximately 12:35 a.m. on January 6, 1999, Employee #1, age 19, was using a Hannifin C-frame trim press to trim aluminum die cast parts. The 12 ton press equipped with two-hand controls for point of operation guarding. This employer typically used handle-activated control buttons on its trim presses that were pulled after the worker placed the parts in the die. Employee #1 was placing a part in the die when the press cycled before she actuated the two-hand controls. Her left hand was on top of the part at the time, and her entire thumb was amputated, as were the top knuckles of her index, middle, and ring fingers. At the time of the accident, Employee #1 had been working as a trim press operator for approximately one month. She had been given on-the-job training that lasted one day but it did not include instructions for daily inspection of the two-hand control functions or cover the hazards of hydraulic trim presses. The employer had many trim presses of this type in its die casting operation and had documented previous instances of trim presses cycling without being activated.