Abstract: At approximately 10:15 p.m., on May 18, 1989, Employee #1 was operating a Pacific 200-ton-hydraulic brake press, New York blower, Serial Number 05282. The press was activated by a foot pedal and did not have two-hand trip buttons. Employee #1 was making a die change and put the bottom die on the press. Employee #1 started to put top die on the ram. When Employee #1 slid the die on the ram he put his hand under the top die to help slide the die into position. When Employee #1 did this he apparently moved his foot and stepped on the foot control. The ram and die came down and amputated the four fingers on his left hand at the metacarpal joints. Employee #1 was then taken to the hospital for medical treatment.