Abstract: At 2:05 p.m. on January 3, 1995, Employee #1, of R. S. Metal Stamping, was operating a malfunctioning 30 ton punch press. The punch press was not cycling the ram as it was designed to do, due to a malfunctioning air activator. The dual hand controls were not guarded as required and were improperly designed. Employee #1 was sanding a pin on a die that was still in the press. He did not lock out or block out the power during this sanding operation. The left hand control (activation) was tied down in the ON position, per employer's instructions. Apparently, while Employee #1 was sanding a portion of the die with his left hand, a tool fell onto the unguarded right hand activation control and the press engaged, causing it to cycle. His left hand was crushed and his index, middle, and ring fingers were amputated. Employee #1 was transferred by paramedics to USCD Medical Center, where he was hospitalized for 11 days. He is presently recovering at home from his injuries.