Abstract: On January 12, 2004, Employee #1, a punch press operator, was working in the metal fabrication department of a glass door manufacturing facility. His supervisor instructed him to perform a lockplate operation, which involves placing three small components together. Once the components are placed into the die mold, the punch press comes down and mashes the rivet shaft which keeps the pieces together. The 22-ton partial revolution punch press, manufactured by Bliss, Model Number C-22, experienced a problem with its light curtain a few months earlier, which required the employer to install a new light curtain with a controller box. Following the repair, the employer tested the machines performance and it was determined operational. Additionally, while performing the lockplate operation, the light curtain was functioning properly. The punch press is always operated by a press pedal. If the foot pedal is not depressed and the operator's his hand enters the light curtain, the press will stop. If the operator depresses the foot pedal while his hand is breaking the light curtain, the press will not cycle. However, if the employee continually depresses the foot pedal, and places his hand through the light curtain, the press will cycle itself, depending on the location of the ram. There is no anti-repeat function. For some reason, a malfunction occurred and Employee #1's right hand came into contact with the press. He received lacerations on his right index and middle fingers, as well as loss of bone on his middle finger. Employee #1 was hospitalized and treated for his injures, which required partial amputation of his right middle and index fingers. Employee #1 was experienced and knowledgeable in the proper operating procedures having operated the press for 7 years. An investigation determined the employer could have prevented the accident by implementing a more effective energy control procedure, properly identifying the function of all control buttons and switches on the power operated presses, color code all control buttons and to conform to the code, and instating tonnage and stroke requirements. Also, the control system was not constructed so that a failure within the system would not prevent the normal stopping action from being applied to the press when required, but does prevent initiation of a successive stroke until the failure is corrected.