Abstract: At 8:00 a.m. on October 7, 1989, Employee #1 was working on an H & J full revolution mechanical power press, serial #7211. She had painted the last of the metal parts with oil and punched them through the 3 station die. She had just stood up from her work stool to get ready for her break when the punch press double tripped, crushing her middle and index fingers. She was transported to Methodist Hospital, Indianapolis, where the tip of her middle finger was surgically amputated. The press did not have point of operation guarding nor were there any type of inspection or maintenance records. The single stroke mechanism disconnects were capable of being locked in the OFF position only.