Abstract: At approximately 5:00 p.m. on February 26, 2002, Employee #1 was working as an operator in Punch Press No. 3C-3, locaed in the stamping shop of the facility. The shop uses punch presses for forming Toyota truck body parts. The machine under consideration is a 300-ton capacity press with 12 to 16 strokes per minute, manufactured by Shimomura Press Manufacturing Company of Japan, machine model number DCLP-300-22E. The punch press is a part revolution machine with emergency stop pushbuttons installed at five locations including at both hand pushbutton panels. Pressing one of these buttons causes the slide to stop immediately. In order to ensure the safety of the operator during the downward movement of the slide, the machine is designed to require the use of both hands to press the pushbuttons continuously until the slide reaches the lower dead point. The machine works two shifts every working day and it makes about 12 different Toyota truck body parts. At the time of the accident, Employee #1 was working by himself. The employee had been working in this machine for four years. While changing die for stamping fuel tank upper part number 7711102100, Employee #1 pressed the two (hand) pushbuttons and the slide went down. As he released his hands, the slide/die eventually went up. Employee #1 leaned forward (across) to reach the air ejector valve for making some adjustments. At that time, the slide came down (for the second time) and struck his right elbow. This amounted to 'double cycling' without actuating the hand push buttons. According to Employee #1, this feature happened a few times in the past. Employee #1 was a regular employee of TABC, Inc. Employee #1 was hospitalized in the Long Beach Memorial Medical Center where he was treated for an avulsion fracture of his right elbow, soft tissue loss, and nerve damage. The investigation determined that no lockout/tag out procedure was followed while adjusting the air ejector valve (during the die change procedure).