Abstract: At approximately 12:15 a.m. on February 6, 2012, Employee #1 was setting-up a 40-ton Chappius horizontal mechanical power press. He was feeding steel coil stock into a pneumatic Festo press feeder. As part of the company's normal procedures, Employee #1 changed the press mode to manual/inch and removed the interlocked barrier guard that protects against the point of operation. In changing the mode to manual, the interlock guard was bypassed. When the barrier was lifted, the press could cycle without the barrier in place. With the barrier removed, the employee could then observe the steel coil's position and movement in the die as the stock is cycled through the die. While feeding the stock into the press, Employee #1's right hand was controlling the die's movement by a single push button. The left hand was either resting on the die when the employee became off balance and inadvertently put the left hand in the pinch point of the die at the same time he inched the press to advance the coil. The press was not locked out at a time the guards were bypassed. Employee #1's middle three fingers on the left hand were amputated below the knuckle.