Abstract: Employee #1 was operating a Federal FSS 55-ton mechanical punch press. The machine had been modified with an air hose to blow finished products from the male die onto a locally manufactured, 12 in. long tool with a rubber suction cup on one end. The press operator would place the suction cup on the product, then activate the air hose. Employee #1 cycled a product through the press, then reached his right hand instead of the tool between the male and female die to remove the finished product. He then activated what he believed to be the air hose, but which was the trigger for the press. The press activated, crushing Employee #1's right hand between the male and female dies. Employee #1 stated that he used his hand and not the tool for this operation because he did not wish to damage the final product. Other employees stated that they had conducted the operation in the same way. If the die came together on the local tool, the tool sometimes pressed into the operator's stomach or other body area. The tool could also mark or mar the product, which would make it unserviceable for painting and to the customer. In addition to employee interviews, a video was used throughout the investigation.