Abstract: On the afternoon of April 5, 2005, an employee was working for a manufacturer of electronic components. She was operating a depaneling machine, which cut printed circuit board assemblies into separate sections. The depaneling machine was a pneumatically operated press that had been designed by the employer. It was a hand-fed, two-hand-trip, single-stroke device. There was an acrylic shield, made of a material such as Plexiglas, located four inches on either side and in back of the outermost point of operation. There was no point of operation guard on the front of the machine where the operator was located. The activation handles were twelve inches apart on center. They were situated in front of the point of operation. When the machine was in use, the operator would align a printed circuit board with its components on the guide pin of the lower die. Simultaneously depressing the left and right handles would activate the ram. The ram would descend and cut the printed circuit board into the number of sections called for in the design. The operator would have been required to lift either the left or right activation handle to raise the ram and complete the stroke. Debris would accumulate on the bottom die after several boards were cut. At the time of the accident, the employee was cleaning the debris, when the ram activated and smashed her hands. The two trip handles would have had to have been energized by pneumatic pressure to activate the ram. The activation indicated that the pneumatic power to operate the press was energized when the employee cleaned debris from the bottom die. The two trip handles were situated in front of the zone of danger and did not protect against unintentional actuation. The trip handles, on twelve-inch centers, were in such a position that when the operator reached into the unguarded point of operation, she inadvertently depressed both of them simultaneously with her arms. The worker was cleaning an energized, unguarded piece of equipment. The unintentional depression of the trip handles caused the ram to activate and descend onto the employee's hands. The force of the ram pressing her hand against the bottom die caused multiple fractures in both hands. The employee was not hospitalized.