Abstract: On November 23, 1991, Employee #1's manager asked her to use a pants presser that she had never been trained to use. As Employee #1 was attempting to press a pair of pants, her left hand and wrist were inadvertently caught between the presser boards. She tried to press the red emergency stop button, but the button was inoperable and would not release the pressers. Employee #1 suffered second-degree burns on her left hand and wrist. After further investigation, it was later found that the emergency stop button was inoperable because the stem of the shuttle valve had been worn down. Air was not released from the cylinder, delaying the release response of the emergency stop button.