Abstract: On May 22, 2002, Employee #1, a temporary employment agency employee, was assigned to the Punch Press (P-11 Rivet Machine). The P-11's form of guarding was a dual palm actuator. After the P-11 completed its cycle of smashing the rivets into the connector, the employee reached up with his left hand to remove the finished piece of product. As the employee's hand was removing the piece out from the point of operation, the P-11's limit switch malfunctioned and allowed the machine to continue cycling. The employee sustained crushing injuries to his left middle finger and pinky finger and was hospitalized.