Abstract: At approximately 2:30 p.m. on Wednesday, December 7, 1994, Employee #1, a 47-year-old die setter, who also served as a press operator, noticed that the Niagara 45-ton full-revolution mechanical power press, model A 3 1/2, serial #35349, double-tripped while he was running the manufacturing stage of a small 2 1/2 inch by 1 5/8 inch part. The press-room lead person and the press-room supervisor gathered with him at this press, then they all took a break. The press had also double-tripped the previous day and that morning. The press was not locked out and de-energized during the break, even with the known defect. After the break, Employee #1 saw that he only needed to complete about 40 pieces to complete the run. So in an unauthorized move, he reached into the lower die to remove a part that had been punched and the press double-tripped, amputating the entire first phalanx on his right thumb. A small, rather inadequate, hand tool had been provided, but, by his own admission, Employee #1 and the other employees rarely used it. Some employee training had been conducted, but with little to no management follow-through, and certainly no employee enforcement of the rules concerning standard operating procedures for the press.