Abstract: Employee #1 worked for a company that made iron members and structures for commercial applications. He was using a 110-ton Mubea KBL 2 1/2 iron worker with plate bar, and a section shear with coper notcher and punch, serial #137/15549/17, when he was asked to unjam a punch stuck on the lower die. Employee #1 opened the front panel above the punch, which housed the ram assembly, and released the jammed punch, raising it to the 'up' position. He then turned on the machine to test if the set-up would still work and initiated a cycle. The doors of the ram housing assembly had gibs to hold and align the ram in place. Without the panel door in place, any downward movement of the ram caused it to misalign forward, toward the operator. Employee #1 was initiating the press when the punch came down and hit the forward, inner lip of the lower die. This caused the punch to chip; a particle flew directly toward Employee #1's chest, impaling him near his heart. He sustained puncture wounds, from which he died.