Abstract: On June 30, 2008, an employee and coworker were operating a Thermo-Press machine equipped with two hand trips, manufactured by Allen-Bradley, Model 800Z-GL3 Series B. They were installed to match the Thermo-Press units. The company had put two-hand trips in place to improve safety. The trips needed to be activated within 0.3 seconds of each other. If only 1 was tripped or if both were not tripped within 0.3 sec of each other, the unit would not cycle. The two hand trips were not equipped with guards over the top of them, which may have assisted in preventing inadvertent operation. Allen-Bradley did manufacture guards for the trips, but Production Manager stated that they were not purchased because they thought that they were not needed. The employee was using Machine Number, when she apparently reached back toward the press head at the completion of a cycle to retrieve the finished part with her left hand. As she reached for a new sheet with the right hand, the unit cycled. The employee suffered severe fractures and burns to the left hand, according to the ambulance service. During the inspection, it was noted that when the metallic paper is dragged across the two hand trip sensor, it activated. It was possible for both trips to inadvertently activate within the 0.3 second timeframe, and the unit to cycle.