Abstract: Employee #1, who worked at a metal stamping shop, was using a 25 ton Chicago Dreis and Krump foot-actuated press brake, model 265, serial #L-17477, to bend a 1 7/8 in. by 8 in. piece of 24-gauge sheet metal. The press brake was equipped with pullback devices, but on a downstroke the pullback on her left hand failed and her hand became caught between the ram and the lower die. Employee #1 called for help, and her supervisor, a setup person, and one other coworker responded. They maneuvered the machine in an attempt to get it into reverse mode, but in their efforts to make the ram go back up they caused it to come down further and complete its cycle. Three of the fingers on Employee #1's left hand were amputated. The main causal factor to this accident was the lack of a blockout procedure. A contributing factor was the company's failure to implement its policy of inspecting the integrity of pullback systems.