Abstract: At or about 3:15 p.m. on March 3, 1994, Employee #1 was operating a Toledo #7 80-ton full revolution mechanical power punch press. She was forming and punching a flat 12 gauge piece of steel that was 23 in. long and 2 1/2 in. wide into a bracket for a van part. The employee would insert the piece into the die area with her left hand, step on the foot control, then remove the part with her right hand. As she removed a part, the press reportedly cycled and caught her fingers in the die area. Three fingers on her right hand were amputated. The employee said that she did not step on the foot control and that the press came down on its own although she was wearing pull backs, which the employer admitted were not adjusted properly. According to the employee, the set-up man set them up for the part before it was formed and forgot that after the part is formed in this press, it is approximately 3/4 in. higher. He forgot to allow for this difference when he adjusted the pull backs for the employee. The next day the company advised all press operators that all parts will be inserted and removed by hand tools.