Abstract: At about 10:20 a.m. on August 2, 1991, Employee #1, of Lee's Pottery Co., put his head between the two dies of a hydraulic power press to clean excessive clay from the back of the bottom stationary die. An eyewitness, who was only about three steps away, saw the ram descending and called to him, but he never answered. He obviously pushed the two control buttons in front of the machine with his legs or other parts of the body while his head was in the dies, tripping the press. Employee #1's head was crushed and he died on the spot. No one had ever seen Employee #1 putting his head in the press in the past two months; this was the first time he was observed working like this. The plant supervisor stated that Employee #1 was trained to go to the back side of the press and remove the excess clay from the molds. Employee #1 had been hired only about 2 months ago, on June 6, and, according to the company management, was trained to operate a hydraulic power press.