Abstract: At approximately 6:00 a.m. on August 15, 2029, an employee finished forming 90 left pieces of metal on the Pacific brake press. The procedure called for a set-up employee to reset the dies for the right pieces so the employee could properly feed the material into the brake press. The employee started forming the right pieces of metal for the order before the dies were changed. The employee placed his hand into the press while positioning the metal material. The employee sustained the loss of three middle fingers and the tip of the pinky on the non-dominant hand and was hospitalized for these injuries.