Abstract: ON MARCH 3, 1984, AT APPROXIMATELY 9:30 AM, EMPLOYEE #1 WAS ATTEMPTING TO PRESS A SHORT SPINDLE INTO A ROLLER, USING A HYDRAULIC PRESS. HE PLACED A CYLINDRICAL STEEL BLOCK BETWEEN THE SPINDLE AND THE HYDRAULIC PRESS CYLINDER. AT A PRESSURE OF APPROXIMATELY 9,000 POUNDS, THE MATERIAL BEING PRESSED SHIFTED, THROWING THE BLOCK FORWARD. THE STEEL BLOCK STRUCK THE EMPLOYEE IN THE HEAD AND LANDED APPROXIMATELY 72 FEET AWAY. THE IMPACT OF THE BLOCK ON HIS HEAD RESULTED IN ALMOST IMMEDIATE DEATH. AMONG THE PROBLEMS FOUND RELATING TO THE OPEATION WERE: THE ABSENCE OF BARRIER PROTECTION, LACK OF FAMILIARITY WITH THE EQUIPMENT, OPERATIONAL NEEDS, AND THE DOOR DESIGN FOUND ON THE HOMEMADE PORTION OF THE UNIT.