Abstract: At approximately 9:50 a.m. on March 20, 1987, Employee #1, age 18, was punching gun sight parts for Browning pistols on a Rousselle 40 ton capacity mechanical full revolution punch press. The safety device was operating but Employee #1 had found a way to circumvent it by placing the press in the full automatic mode. The press must be periodically retimed by keying it to the automatic position so that it can be jogged on full revolution and placed back in proper timing. Employee #1 keyed the press to automatic mode, retimed the machine, but failed to key it back off automatic. He placed a piece of material on the press with his right hand and hit the triggering knob with his left elbow, energizing the press. The ram came down, amputating his right index finger.