Abstract: On October 3, 2011, Employee #1 was changing die plates on a hydraulic rotary press. Apparently, new presses had the die plates attached to the underside of the press head, which lowered to the anvil that contained the blank metal friction disk being created. Older press models had the die plate mounted to the press head at the bottom, where the blank disk was placed. When the cycle initiated, the head raised to the anvil mounted on the upper part of the stroke. During the investigation, the Compliance Safety and Health Officer determined that Employee #1 had discovered a faster, easier method for a single operator to perform die changes on a newer model press. Employee #1 had discovered that he could partially disconnect the installed presence sensing device (PSD), light curtain, on the hydraulic rotary press, which would allow him to access the rotary press dies. By bypassing part of the PSD, Employee #1 was able to access the maintenance control lever on the upper part of the press, inside the normally PSD controlled area of the press enclosure. He could then operate the press in its manual maintenance mode, and "jog" the "joystick" type actuator lever on the upper part of the press frame to access the rotary press dies in incremental actions. Employee #1 started the operation with the "FAS #13" press in the lowered position and removed the two mounting screws holding the upper die plate to the press head. He then operated the actuator lever with his right hand to raise the press head. When he observed the unsecured die plate start to fall, he placed his left hand into the open space to prevent damage to the die. As he inserted his left hand between the plate and lower head, he inadvertently moved the actuator lever with his right hand and lowered the press head onto his hand. When the press cycled, it amputated Employee #1's left middle finger and partially amputated his left ring and index fingers. Employee #1 was hospitalized.