Abstract: Employee #1, a 15-year-old student and part-time worker, worked for a retailer of handicraft materials. Although the employer owned a large retail outlet, they also had several satellite facilities where they repacked materials they purchased in bulk for retail consumption. At the site of the accident, workers were bagging fabric rounds in plastic bags, stapling headers and punching holes into them so that the rounds could be hung on display racks. Employee #1 was using a pneumatic punching press that operated at less than 100 psi to punch T-holes into headers. The press, which had been made specially for the employer, was on a table; the operator would sit in front of the press and activate it with a foot-ooerated device. Employee #1 was punching three headers at a time, holding them at each end and actuating the machine with his right foot. As each task was finished, the scrap materials from the headers would be stripped out of the upper hollow blade and would remain on the table, directly underneath the point of operation. Employee #1 would then have to remove this pile of six pieces of scrap by hand to facilitate the next group of headers. At the time of the accident, he was clearing the scraps when he moved his right foot backward. His heel came down on the foot pedal, actuating the machine and amputating his right index finger to the first joint. Three causal factors included (1) failure to provide and enforce the use of extension tools to clean the machine; (2) the lack of guarding (housing) on the foot-operated device; and (3), and insufficient guarding at the point of operation.