Abstract: On the morning of March 13, 2006, Employee #1 was a temporary worker who had been at his job for about one-and-a-half weeks. He had been assigned by the plant manager to make a run of parts on a Johnson 60-ton, full revolution clutch punch press. The press was used once per year to make one part for one customer. It was not used to make any other parts. Making the piece called for two operations. First, the piece was placed in the die by hand, and a first hit was made. Then, the piece was removed from the die and turned lengthwise for a second bend. The press was equipped with restraints and two hand trip buttons. The restraints and the two hand trips had been put on the press on the recommendation of a safety consultant. Additionally, however, the press had a foot switch. Aluminum tongs were to be used to position and remove the workpiece. These were to be in conjunction with the restraints. Nonetheless, fingers on both of Employee#1's hands were badly crushed by the die as he held the workpiece in place for its second bend. He was hospitalized. The investigation revealed many discrepancies. The plant manager said that he set up the press and instructed Employee #1 on how to make the run. He said he adjusted the restraints for Employee #1 and reminded him to use the palm buttons. He said he watched Employee #1 run the press for a while and then left him to do the work. When he left, he said, Employee #1 was using the palm buttons and the restraints as instructed. The plant manager was asked, in the presence of another management official, if the tongs were being used at the time of the accident. He replied that he had not required Employee #1 to use them, because he did not feel that they were necessary. Because the die set had been removed from the press, he explained that the part did not have to be held in place to make the second strike. The company owner, when asked how to reconcile the use of restraints with an operation in which hands were in the die, explained that aluminum tongs were to be used with the restraints. Employee #1 was shown a photograph of the press and asked to describe the operation. He explained that he made the first hit with the palm buttons and then supported the part by hand for the second hit, tripping the press with the foot switch. Looking at a photograph of the press, he asked where the foot switch was. He was told that there was no foot switch, and that the press did not have one when it was inspected the day before. He was also told that both hits were made with the palm buttons, and that there was no foot switch on the press. Employee #1 argued there had to be a foot switch. He had to support the work piece with one hand to make the second hit, and he couldn't do that while using the two palm buttons. Employee #1 was not aware of "what the restraints were." When they were pointed out to him in the photo, he said that he had never seen them before. The owner was made aware of the discrepancies between Employee #1's explanation of the operation and the plant manager's. The owner said that the plant manager's explanation of the operation during the investigation was how it had been described to him as well. The owner indicated he had not seen the operation on the day of the accident and was unaware that there was a foot switch or that the restraints were not being used. A coworker who was interviewed indicated there was a foot switch on the press, and that the restraint straps were lying on the floor during the operation. The plant manager, when again interviewed in the presence of the owner, said that he had not required Employee #1 to use the restraints during the accident. He was asked if there was a foot pedal and stated "no there was not." Later, the discrepancies were again pointed out to the owner, who agreed to discuss the matter with the plant manager. The owner reported back that he had now learned from the plant manager that there was a foot pedal "on the floor behind the press" and