Abstract: On August 13, 2005, Employee #1, an employee of a bed manufacturing company, was attempting to adjust the nozzle of a pneumatic line, which was used to kick parts out from the die of a punch press. The machine was a full-revolution type punch press manufactured by Frederick Engineering, Model Number 1250, Serial Number 3060, and was identified by a Shop Number 6. The press was not deenergized or blocked out and its activation switch consisted of a lever device operated by using one hand. Employee #1 reached in between the die shoes behind the die to move the nozzle when his torso activated the press. His left arm was amputated above the elbow. He was hospitalized.