Abstract: On June 22, 2006, Employee #1 was working as the operator of an E.A Kinsey Co. full-revolution mechanical press. The press's barrier guards were not in place, and the foot pedal was positioned close enough to the press that an operator's hands could enter the press's point of operation during the cycle of the press. Employee #1 was using a foot pedal to initiate the cycle, when two fingers on his left hand were partially amputated. He was not hospitalized. Through employee interviews, it was established that the employer had removed the foot pedal and installed a set of two-hand trips on the press. The employer then released the press back into operation prior to an inspection held on July 17, 2006. During the inspection, it was found that the two-hand trips had been installed in such a fashion that it was not necessary that the buttons be pressed concurrently to activate the press. Further, the barrier guards were designed so that an employee could reach over, through, or in between the guards into the point of operation.