Abstract: At approximately 8:35 a.m. on January 14, 2005, Employee #1, a machine operator, was operating a mechanical press brake, Dreis-Krump, Model Number 8L10, manufacturing light fixtures. She was forming metal parts and was operating the press brake with two-hand buttons. The press brake could only do a single stroke upon activating both palm buttons. After forming the part, she placed her hand in-between the dies to remove the part, but the ram unexpectedly moved up and down continuously causing repeated strokes without anyone activating the machine. The upper die came down on her fingers and amputated four left fingers. The Plant Manager and a machine operator indicated that they could not stop the ram from moving up and down despite switching the controls to the off position.