Abstract: At approximately 4:10 a.m. on September 29, 2009, Employee #1 was operating a Toyokoki press brake, Model Number HYB-85, Serial Number 1445, Manufacturing Number 7004304. His employer specialized in the manufacture of animal care and incubator units, as well as chicken debeakers by sheet metal fabrication. Employee #1 was instructed to alter a 10 foot aluminum-tube coil into a heating coil by adding dimples to it. Specifically, he was to take about a 1 foot section of coil and slip that onto a 2.75 inch outside diameter (OD) mandrel. The device was placed on the press, using a v-support with a 0.13 inch opening above the stock. Employee #1 then began operating the press by the right foot pedal, lowering the ram to press the dimples in the coil with dies. He repeated this four times and then turned the coil one-quarter of a revolution in a counter clockwise direction towards him. As Employee #1 was rotating the part by putting his hands around the coil with his thumbs on the bottom of it, he engaged the foot pedal and the ram, with its dies attached, came down onto his fingers. Several fingers on his right and left hands were crushed. Emergency services were contacted, and Employee #1 was taken to Scripps Mercy Hospital in San Diego, CA, where he was hospitalized and underwent surgery for his injury. His injury resulted in the amputation of a finger on his right hand (an approximate 1.5 inches removed), as well as the partial amputation of the tip of his left index finger. Additionally, two other fingers on each hand were fractured. The incident investigation revealed that Employee #1 did not have the dies properly adjusted, failing to place the dies 0.13 inches above the stock. Instead, the dies were adjusted with an opening at 2.75 inches.