Abstract: At approximately 7:00 a.m. on June 21, 1986, Employee #1, the lead die set-up person, told the die setter to change the die in the Verson mechanical power press, model #150-52-22. The press was put in the inch mode and the ram was brought to dead bottom. The die setter could not raise the press ram using the rise control, which would bring it up slowly, so he told Employee #1 to call maintenance. Instead, she climbed onto the press bed, leaned over the top of the ram, and tapped on a micro switch with a bolt. As she started to get down off the press, her right arm or hand contacted with the inch control button, actuating the press and cycling the ram. Her head was pinched between the top of the ram and the press crown. She was transported to University Hospital, where she died at 9:15 a.m. of severe head injuries. The inch control button was not guarded against accidental contact. The die setter had twice told Employee #1 to get off the press and let maintenance take care of it. Employee #1 violated company safety policy by climbing on the press bed while the drive motor was running.