Abstract: On January 5, 1990, Employee #1 was stamping identification tags for pumps with operating information in the punch press 005 department. The stamping was done on a Rousselle, Model 1A; ten-ton mechanical clutch- operated full-evolution power press, operated by a foot pedal. A die, mainly manufactured at the facility, was being used for the first time in a production mode. No type of point of operation guard or device was being used at the time of the production. Part of the tags became stuck and Employee #1 used his hand instead of a provided hand tool to reach into the point of operation and back it loose. He apparently tipped the press by the foot pedal and caught three fingers of his left hand in the die.