Abstract: At approximately 7:35 a.m. on August 6, 1997, Employee #1 was using a hydraulic press with a two-hand control device to make a 0.31-in. by 3-in.-long key receptacle in a part being fabricated. On this particular press, both buttons must be depressed for the press to go through a cycle. The press retracts when pressure is taken off one or both of the buttons. Because both hands must be used during the entire cycle, the operator's hand cannot get into the point of operation. As Employee #1 was reaching with his right hand to remove the finished part from the die, a safety ratchet bolt broke allowing the ram to fall on Employee #1's hand. The safety ratchet holds the ram in the upright position. The safety ratchet requires four bolts, but three of the bolts were missing. The one remaining bolt failed and allowed the ram to fall. The bolts are not visible from the front of the press. Employee #1 sustained puncture wounds to his hand and also had part of his middle finger removed as a result of the accident.