Abstract: On October 3, 2005, Employee #1 was a contract employee working for a manufacturer of automotive parts. She had been placed through a temporary hiring agency. She was operating a Manchester Model Number M71-H-3 hydraulically operated tube end forming machine, with Serial Number 0100-03772. This machine forms mating ends on the metal tubes used in automotive heating and cooling systems. The tube to be worked on is placed in a clamp by hand. The clamp closes horizontally and holds the tube in place while two separate horizontally moving rams, fitted with specialized tools, hit the tube end sequentially to shape it into the desired form. Then the holding clamp releases the finished part, and it is removed by hand. For small pieces, an extension tool is used for inserting and removing the part from the clamp. The entire cycle is initiated by a foot pedal. At the time of the accident, Employee #1 was operating the machine, when a finished part did not come out with the extension tool she was using. The part slipped off the extension tool and stayed back in the clamp. To remove it, Employee #1 reached into the clamp with her left hand. As she did, she accidentally pressed the foot pedal. The clamp closed on her hand. The index finger on her left hand was crushed. She was taken to the emergency room of a hospital, where two-thirds of the finger was amputated. She was not hospitalized overnight. All four sides of the machine she was running are enclosed by interlocked doors made of acrylic glass. Until the accident, the opening through which parts were fed into the machine was large enough for the operator to reach into the holding clamp. After the accident, the employer modified the cover to restrict the feed opening to be approximately 1 in. by 1 in. This opening is small enough to inhibit an operator from reaching into the clamp without opening the interlocked door, which would stop the machine immediately.