Abstract: At 10:45 p.m. on March 26, 2004, Employee #1, a full-time welder working for Western Conveyer Systems, was operating a Betenbender hydraulic shear. The machine had a serial number of 163100 and model identification of 8-1/4. The employer manufactured trusses, conveyors, bins, hoppers and surge tunnels. Employee #1 was pushing a piece of 12-gauge sheet metal towards the unguarded blade of the machine. Somehow, Employee #1's right hand made contact with the shearing blades and he suffered amputation of the first joints of his right index, middle and ring fingers. Employee #1 was hospitalized for over 24 hours. Surgeons were unable to reattach the amputated digits. The hydraulic shear was routinely used by employees in the light metal shop without a protective guard. Employee #1 was taught to operate the machine without the guard by a coworker. Employee #1's supervisor did not inspect the machine before assigning him to use it. The supervisor later found the guard lying along the wall in the shop. There were no direct witnesses to this incident.