Abstract: At 8:25 a.m. on November 2, 1991, Employee #1 was at the Johnson OBI-60 punch press, punching door holes in 25 3/4 in. by 42 5/8 in. light gauge metal sheets for use as rain gauge panels. He had changed the press activation mode from two-hand trip to foot pedal so he could hold the sheet in his hands to position it by two sheet holes on two 1/8 in. diameter by 1/8 in. high pins in the dies set up. The sheet, because of its light gauge, tended to slip off the pins. Employee #1 was using his right hand in the unguarded 3 1/2 in. opening between the dies to position the sheet when his left foot accidentally hit the foot pedal. The press activated and the upper die descended, crushing his right hand and forearm, which were later amputated below the elbow. Training in safe die set up and press operation was lacking, and the two-hand trip mode should have been kept or the die opening should have been guarded if a foot pedal was to be used.