Abstract: At approximately 12:45 p.m. to 1:00 p.m. on July 19, 2006, Employee #1 was working as a press operator at a metal stamping facility. That morning, the press had been operated from 5:00 a.m. to lunch at noon. Employee #1 started up production again after lunch at about 12:30 p.m. This press had dies in two positions, position "A" and position "B," located one in front of the other. Employee #1 was removing a part from die position "A" to move it to position "B." To do so, he had to reach through the cavity to place the part in the "B" die. As he had his hands in the cavity, the upper die in position "A" fell, crushing the left side of the index finger on his right hand at the second knuckle and causing a contusion to the right thumb. He was hospitalized. The four bolts holding the die had simultaneously worked their way out of the upper plate, allowing the die to fall. The press had been operating approximately five to six hours that day, and Employee #1 had run 450 to 500 parts that morning, when the accident took place. After the event, the assistant supervisor-forming, the firm's owner, and a tool and die maker went back to the press and inspected the bolts, the upper plate, and the die. They could not find any reason for the bolts to have backed out. The bolt threads were good, and the threads in the upper plate appeared fine, except that the bottom thread in all four holes was slightly pulled out.