Abstract: Employee #1, a printing operator, was using a Minister #5, 45 ton capacity punch press to punch out dial readings on a metal template she had just printed, verifying that the printing was properly centered. The press had a two-hand trip and pullback safety devices. Employee #1 placed a template in the press, cycled the press (single stroke), and turned the template around. She cycled the press again, then reached in to retrieve the template. The press started a continuous cycle and caught Employee #1's left hand and amputated part or all four fingers. Employee #1 was not using the pullbacks. The employer required that the two-hand trip and pullback devices be used while operating the press. Employee #1 had been trained on the press and had operated it for 4 years.