Abstract: AT APPROXIMATELY 10:15 PM ON THURSDAY, JANUARY 2, 1992 (THE FIRST DAY OF PRODUCTION AFTER A CHRISTMAS/NEW YEAR PLANT SHUTDOWN) EMPLOYEE #1 SUFFERED AMPUTATION OF PARTS OF HIS MIDDLE AND RING FINGERS OF HIS RIGHT HAND. AT THE TIME HE WAS PLACING AND REMOVING A CLUTCH BEARING PART INTO THE POINT OF OPERATION OF A MULTIPRESS 18 TON HYDRAULIC PRESS. THE EXISTING PRESENCE SENSING LIGHT CURTAIN SAFETY WAS BYPASSED BY A POORLY ADJUSTED "2LS" LIMIT SWITCH, WHICH IS DESIGNED TO STOP THE DOWNWARD MOTION OF THE RAM AND DIE AT THE POINT WHERE IT ALMOST TOUCHES THE PART. HOWEVER, THE "2LS" LIMIT SWITCH WAS ADJUSTED SO THAT THE RAM STOPPED AT A POINT ALLOWING 1 INCH OF SPACE BETWEEN THE DIE AND SHOE, MOUNTED ON THE BOLSTER PLATE. THE PRESS WAS ACTUATED BY A COVERED FOOT PEDAL. EMPLOYEE #1 WOULD PLACE THE PART INTO THE DIE FIXTURE WITH HIS RIGHT HAND AND REMOVE IT WITH HIS LEFT HAND. HE HAD 6 MONTH EXPERIENCE AT THE JOB AND WAS CROSS TRAINED TO PERFORM A VARIETY OF ASSEMBLING OPERATIONS ON OTHER MACHINES. THE COMPANY HAD A POLICY OF RESTRICTING EMPLOYEE WORK AT ANY ONE JOB FUNCTION TO A PERIOD OF 2 HOURS OR LESS. THE PRESS SET-UP THEY WERE USING WAS NOT EVEN INTENDED FOR THE ASSEMBLY OF THE PART THEY WERE WORKING ON. THE NEED TO HAVE THE "2LS" LIMIT SWITCH OPERATIONAL WAS MEANINGLESS TO THEIR OPERATION. THERE WAS NO POLICY FOR EITHER THE SET-UP PEOPLE OR THE OPERATORS TO PERFORM SAFETY CHECKS ON EACH SHIFT. OPERATOR TRAINING WAS INADEQUATE. WORK ON THIS PARTICULAR CLUTCH BEARING ASSEMBLY OCCURS FOUR DAYS A MONTH. A SERIOUS "NEAR MISS" ACCIDENT HAD OCCURRED ONE WEEK EARLIER WHEN ANOTHER OPERATOR'S GLOVE WAS NIPPED IN THE POINT OF OPERATION, BUT THAT ACCIDENT WAS NEVER REPORTED TO MANAGEMENT.