Abstract: On September 2, 2004, Employee #1, a machine operator for a company that manufactures cylinders, pressure vessels, and aluminum shells for self contained breathing apparatuses, was operating a draw bench. The manufacturer of the machine is MJC Engineering of Huntington Beach and it was custom built for the employer. Therefore, no model or serial numbers were assigned to the machine. The draw bench consists of a ram or punch, which moves horizontally and is actuated by a lever. The ram center height is 40 inches from the floor and the maximum horizontal distance the ram travels is 24 inches. At the other end of the machine bed, which looks similar to an engine lathe, there is a die that is mounted inside a die holder. The tip if the ram or punch, with a part attached, advances towards the die and the job, inside the die, assumes the interior profile of the die. The punch travel is then reversed and the part being produced is then stripped out at the die end. While the machine was going through one of its operation cycles, Employee #1 manipulated the control lever with his left hand and placed his right hand on the job which was just loaded on the punch. The tip of his thumb on his right hand became caught between the ram and the part. Employee #1 stopped the controls and called for help. Some coworkers came to his assistance and reversed the punch in order for Employee #1 to release his hand. Employee #1 was transported to UCI Medical Center in Irvine, CA, where he was hospitalized and treated for the amputation of the tip of his right thumb. The accident investigation revealed that there was no provision, such as a guard or point of operation device in place to avoid injury. Employee #1 was wearing gloves on both his hands at the time of the accident.