Abstract: On December 7, 2011, Employee #1 was at an automobile engine valve plant feeding heated bar stock steel into a Bliss 150 mechanical power press (K-400) equipped with a shear die. She was preheating the stock with a Tocco Unit Number K227 to a temperature of approximately 400 to 420 degrees Fahrenheit to facilitate the cutting process. The investigation determined that Employee #1 had bent over in the space between the press and the bar stock feeder to pick up a bolt, metal shim and washer that had fallen off a recently-installed interlock system on the press. Employee #1 was found unresponsive by a coworker, pinned between the bar stock feeder and the press, with heated bar stock penetrating into her right upper back just below the shoulder blade. The coworker extricated Employee #1, who was not breathing. The coworker summoned assistance while a second coworker administered CPR. Buffalo County Sheriff Deputies were the first on scene and they took over CPR, followed by EMTs from the Good Samaritan Hospital. Employee #1 was resuscitated and transported to Good Samaritan Hospital with third-degree burns to her back, internal organ failure, and fractured ribs. She died on December 23, 2011.