Abstract: On March 27, 2006, Employee #1 was operating a bulldozer-type press that shaped capacitor clamps. The process required that the employee reach into the point of operation and place a flat metal blank into the die. The employee then depressed a foot pedal to actuate the press, and the press cycled. After the finished part would be removed from the die, a new blank was placed in, and the cycle was repeated. Employee #1 stated that she was reaching in to remove a completed part when the press cycled, partially amputating her left third and fourth fingers. The investigation revealed that the machine was not equipped with any type of guarding which would prevent the employee from reaching into the machine. The company also did not have a written safety and health plan, nor did they provide proper training.