Abstract: At 10:55 a.m. on April 19, 1989, Employee #1 was cleaning scrap metal from the die area by hand. While she was at lunch, the press was serviced by tool and die department workers, who had turned off three of the four control stations that would be used during normal operations. Operator Station #1 had been left activated. When the four operators, including Employee #1, returned from lunch, one of the other operators unknowingly activated the press, amputating Employee #1's right arm. The press was equipped with four two-hand concurrent constant pressure devices as well as two light curtains on both the front and rear. During cleaning, Employee #1 had moved in past the light curtain and consequently was not protected. Causal factors for this accident include the fact that the operating personnel had not been warned about the service operations and that the press had not been tagged. In addition, when the operators returned from lunch the service personnel had already left the area of the press. The tool and die supervisor, who had returned to the area prior to the accident to check the setup of the press and to make sure that all of the stations had been turned back on, said nothing to the operating personnel about the potential dangers of operating the press. To access the press's control panel, the tool and die supervisor had to walk past Employee #1 as well as by the employee who activated the press.