Abstract: On June 6, 1985, Employee #1 was pressing coils of 28-inch wide by 0.01-inch thick steel ribbon into 28-inch-square forms to be used as computer bases. The forms were pressed using a Dominion 2000-ton press Serial Number MW-461-1 and a Coe Press Equipment feeder Serial Number E-121118-CF-500. Personal protective equipment, the presence-sensing device, the two-hand trips and the switches were all operating. The employee was standing to the left of the press center when the steel jammed in the die. The employee admitted that he did not call a mechanic or leader but, instead, tried to force the piece out by automatically feeding more steel. As a result, the jammed piece flew out of die and struck the employee's left forearm, causing a four inch cut that required ten stitches to close. Other causal factors were the employee failed to recognize a hazardous condition, neglected to check adjustments on the Coe feeder, and continued to operate despite seeing the piece in the die was defective. Employee #1 had three months of training and had been working on his own for one month.