Abstract: Employee #1, a power punch press operator for Waterman Industries, Inc., was cutting out 3 3/8 in. by 1/16 in. thick Teflon gaskets. He had selected the two-hand/single mode, and the setup was checked by the lead person. Shortly after setting up, the operator, on his own initiative, turned the control key switch from two-hand/single to foot/single operation. While removing the product by hand, Employee #1 inadvertently activated the guarded foot control. The slide came down and crushed both his hands. Employee #1 was transported to Kaweah Delta Hospital in Visalia, CA, for treatment. After he was evacuated, the lead person checked the key control switch and found it in the foot/single mode, not the two-hand/single mode they had originally selected and approved. The employer's policy called for the shop supervisor, the lead person, and the operator to have possession of a control key, with the operator's key left in the control to select the operating modes. The change to foot/single operation required point of operation guards, which were not in place.