Abstract: At 3:30 p.m. on August 4, 1992, Employee #1 reported to work at 3:30 p.m. and was assigned to stamp out a steel handle on a Niagara A45 mechanical power press, which had a two-hand pull back device. The die setter had adjusted the pull back device before Employee #1 started work. According to Employee #1, he was wearing cotton gloves and using the safety pull back straps. After slowly stamping out a few parts to ensure that the dies were producing a good part, Employee #1 started normal production. When he reached for the die, the press tripped, closing the dies on his left hand. Four of his fingers were amputated. According to the employer, Employee #1 was not wearing the pull backs. The die setter did not ensure that the pull backs were on or properly adjusted to Employee #1's reach.