Abstract: On March 8, 1989, Employee #1 was performing his regularly assigned job using a 50-ton Cincinnati 350 mechanical press brake for the metal fabrication of garden gates. The press was equipped with two actuating devices: a covered foot pedal that was normally used when large pieces of material requiring two hands for holding are in the machine, and two-hand palm buttons that were used for smaller parts. The palm buttons could be moved anywhere along the length of the machine's body and secured in place. Employee #1 was working with 40-in.-long 0.75-in. galvanized steel tubing with both ends bent that would later be used as the gate's perimeter frame. His task was to place the tubing the left end of an installed die. The brake would place one curved portion in the die, while the other end rested in a holder secured to the back of the left side. The die would then create a hole in the tubing for screws during later assembly. When done, the employee would reverse the ends of the tubing, then remove the tubing and start with another. For this operation, Employee #1 was using the foot pedal and not the palm buttons. The employee had his thumb crushed in the press brake. He was hospitalized for his injuries.