Abstract: Employee #1 was operating a mechanical power press with a full revolution clutch to punch a neoprene-like material that would be used by the postal industry for mail sorting. This equipment was provided with an automatic air-powered material feeder; however, misaligned or exhausted material had to be fed manually. Employee #1 had his fingers in the danger zone while manually re-feeding the stock. The unit cycled, causing the ram head to come down on his fingers, trapping both hands. Employee #1 suffered full or partial amputation of fingers on both hands. A hand tool was available to prevent entry into the danger zone, but this tool was not used. This equipment lacked point of operation guarding, a single-stroke mechanism, and guarding for the foot pedal to avoid unintentional cycling of the ram head.