Abstract: A CREW OF FOUR EMPLOYEES WAS OPERATING A SHERIDAN MODEL 50 DIE CUTTING PRESS, S 77 372. THE MACHINE IS USED TO FORM AND NOTCH CORRUGATED PAPER BOXES. ONE EMPLOYEE WAS FEEDING THIS MACHINE. EMPLOYEE #1 WAS WATCHING THE DISCHARGE POINT OF THE MATERIAL, ABOUT THE MIDPOINT OF THE MACHINE. TWO OTHER EMPLOYEES WERE REMOVING THE PROCESSED MATERIAL FROM THE TAIL CONVEYOR OF THE MACHINE. THE MACHINE JAMMED, DUE TO BREAKAGE OF THE FINGERS AT THE DISCHARGE POINT. THE BOXES THEN BECAME CAUGHT IN THE MACHINE. EMPLOYEE #1 TURNED OFF THE MACHINE, THEN CRAWLED UP INTO IT TO REMOVE THE JAMMED BOXES. THE MACHINE OPERATOR, WHO INTENDED ONLY TO JOG THE MACHINE, ACCIDENTALLY STARTED IT UP. EMPLOYEE #1'S HEAD WAS AMPUTATED AT THE NECK BY THE ROTATING GRIPPER BAR. EMPLOYEE #1'S STOP SWITCH HAD BEEN RELOCATED SO THAT THE MACHINE COULD BE STARTED FROM THE OPERATOR STATION ONLY, INSTEAD OF TWO STATION CONTROL, AS THE MACHINE WAS DESIGNED.