Abstract: At approximately 3:30 p.m. on November 2, 1995, Employee #, working for a company that manufactures parts for office furniture, was operating a foot-powered Bliss full revolution mechanical punch press, model 23, serial #2021, without pull backs. The machine was equipped with a guard but it was loose and damaged. The machine cycled as Employee #1's left index finger slipped off the part being held in place on the die and was crushed by the press. The accident causal factors were an inexperienced operator, defective point of operation guard, the absence of palm release buttons, and the requirements and order not to use the installed pull backs.