Abstract: At 2:18 p.m. on October 30, 1998, Employee #1 and a coworker, who worked at a foundry that produced ingots of super alloys, were standing on opposite sides of the ingot push-out mechanism. This was a shop-made tool consisting of a cradle into which the completed ingot dropped, a hold-down clamp, and a hydraulic ram that pushed the ingot from its mold. Employee #1's function was to check the alignment of the ingot in the cradle, after which the coworker activated the hold-down clamp and the hydraulic ram. As one ingot dropped into place, Employee #1 saw that it was not aligned properly, so he adjusted it with his right hand. The coworker, standing on the other side of the press, prematurely initiated the hydraulic hold-down mechanism, catching Employee #1's hand between the ingot and the clamp. He suffered acute crushing injuries and was transported to the hospital, where he underwent surgery. The point of operation was not guarded, and there was no two-man control mechanism. The employer was cited for a citation (serious) of T8CCR 4184(b).