Abstract: At approximately 2:50 p.m. on May 17, 1989, Employee #1 was operating an L & J 50 ton punch press to form 1 1/8 in. by 34 in. long pieces with a press brake-type die set. To achieve the close tolerances required for these parts, Employee #1 had to lower the ram adjustment to get the worn shop-built dies to close adequately. After the ram of the press stopped at the top of its stroke on the 43rd part, Employee #1 reached into the dies with his right hand to retrieve the part. The clutch key broke and the ram came down on his hand. Employee #1 pulled his hand back as the dies opened and the machine continued to stroke. Portions of all four fingers on his right hand were amputated.