Abstract: ON APRIL 12, 1984, AT APPROXIMATELY 9:35 AM, EMPLOYEE #1 WAS CLEANING THE NORTHWEST CORNER OF THE DIE IN PRESS V-1 (DANLY QDC D44-1250-144-96). AT THE SAME TIME ANOTHER CREW WAS WORKING ON THE DESTACKER. THIS CREW WAS UNAWARE OF THE PRESENCE OF EMPLOYEE #1 AT THE DIE. WHEN THE CREW FINISHED WORK ON THE DESTACKER THEY REPLACED THE INTERLOCKS THEY HAD REMOVED AND RESET THE DESTACKER SYSTEMS. THEY THEN TURNED THE PRESS ON. THE PRESS COMPLETED ONE CYCLE, CRUSHING THE HEAD OF EMPLOYEE #1 BETWEEN THE TOP DIE AND A FEEDER GUIDE ON THE LOWER DIE. SUBSEQUENT INVESTIGATION REVEALED THAT THE INTERLOCKS LOCATED ON THE PRESS WERE IN PLACE AND THE SYSTEM WAS FUNCTIONAL, INDICATING THAT THE PLUGS HAD NOT BEEN REMOVED. THE INTERLOCKED BARRIER GUARD AT THE NORTHEAST CORNER OF THE PRESS WAS NOT ADJUSTED CLOSE ENOUGH TO THE TURNOVER/CONVEYOR TO PREVENT THE EMPLOYEE FROM ENTERING THE POINT OF OPERATION AREA WITHOUT REMOVING THE INTERLOCK.