Abstract: Employee #1 operates a single stroke punch press. The press is equipped with two hand controls that require concurrent use of both hands to activate the clutch. The controls are protected against unintentional operation and are arranged in a manner to hand actuate if necessary. Employee #1 was provided with an instrument to remove formed parts. On the day of the accident, Employee #1 used his hand instead. A cam shaft brake was out of adjustment, and when the press cycled, the die struck Employee #1's finger. Although the machine malfunctioned, the accident was caused by Employee #1 using his hand instead of the provided tool to remove the product from the die. The company provided records and verbal testimony of training as well as records showing that functional performance checks were conducted at least once a week.