Abstract: At approximately 10:30 a.m. on October 7, 1988, Employee #1, a packager, was preparing to change the die on an Ampak Rotomatic machine. He was preparing to change the bottom Plexiglas plate when the machine engaged. As the roller on the top of the die area began to come forward, it pushed the hood of the die down. Employee #1 pushed the emergency reverse button for the roller to go back into the starting position, but instead of reversing, the roller came forward, catching his right hand in the die area. His right hand was lacerated and several fingers were amputated. According to the employee, he did not have his hands on the operating button.