Abstract: At approximately 2:17 p.m. on November 17, 2008, Employee #1 operates a 45-ton punch press machine, a Hidaka, Type Mark-45-11, Control Number 000019, Machine Number 123, asset Number 87PP040. This press cuts various copier machine parts from sheet metal, which is laid flat under the master die on a table area. The die is attached with bolts to the bottom portion of a moving ram. Employee #1 has to push both buttons on a two-button controller. A light curtain also surrounds the machine to stop the operation process if any body part breaks the plane of the light curtain. One of Employee #1's duties includes changing the die approximately one to five times a week. He was removing the die and changed the machine from run mode to the jog mode. He loosened the bolts on the die that keep it in place on the moving ram. The normal operation would be to run the machine in jog mode using the two-button controller, which would raise the machine's ram, and the die would separate. Employee #1 was unaware that he had not completely loosened a bolt. He started to operate the machine in the slow jog mode and the die did not separate from the machine. The die raised approximately 6-in. Employee #1 noticed that the die was not completely removed and stopped the machine. He stepped towards the machine and put his hands under the machine's ram that was holding the die. The bolt that was holding the die loosened, and the approximately 200 to 240 pound die fell onto his finger tips. Employee #1's finger tip was amputated.