Abstract: On September 20, 1991, nine operators of American Bumper and Mfg. Co. were working on a part-revolution mechanical power press with only six sets of safety controls. The operators reached into the press, expecting the ram to stop at the top of the cycle. Instead, a part broke in the clutch/brake system and the press continued to cycle, crushing Employees #1 and #2 to death and injuring a third employee. The brake monitor, a safety device to detect faults in the clutch/brake system, was disconnected. Die setting procedures, which provide assurance that safety devices are properly adjusted and functioning before a press is put into production, were not followed. Training for the operators and maintenance personnel was inadequate. Press inspection records and follow-ups on previous operating problems were found lacking.