Abstract: At about 2:30 p.m. on May 6, 2005, Employee #1 was operating an automatic hot foil press, using a foot pedal to initiate movement. The machine was guarded by a sliding guard plate with interlock switches, but the plate was poorly adjusted. As Employee #1 was placing material in the point of operation of the machine, his foot inadvertently pressed the foot pedal. The machine's ram closed at the point of operation, crushing his hands, and fracturing a number of bones. He was also severely burned by the press plates, which were operating at a temperature of about 2,100 degrees F. Employee #1 was hospitalized. His injuries required extensive treatment. The employer was cited for the improperly adjusted guard.