Abstract: On January 29, 2008, Employee #1 was working as a Die Cutting Operator for Pre-Press International, Inc., dba DPI, in San Francisco, CA. Employee #1 was assisting a coworker, operating a manually-fed job platen press, also known as the flatbed creasing and die cutting machine. The tag affixed on the front of the machine had the following information: Creasing and Cutting Machine, ML 14001400 by 1000 mm 18 per minute SN: 8080028, Yawa Printing Machinery Co., LTD The manually-fed creasing and die cutting machine was not equipped with modern safety systems (e.g., guards, devices, signaling) to protect the operators during die setting (removal and placing of dies) and normal operation of the machine. At Approximately 11:25 a.m., Employees #1 and the coworker had finished a job which involved a large size die, and were about to start a new one utilizing a smaller die (22 in. X 26.5 in.) The platen working surface is approximately 40 in. by 55 in. (1000mm by 1400mm). They were positioning the die on the stationary platen. The coworker, who was the main operator of the press, was standing on the right side of the machine while Employee #1 was standing on the left side of the machine. The coworker started to secure the die between the upper and lower clamps on the stationary platen from its top right hand corner using a special wrench. When she then noted that the moving platen had been activated and was about to close on them. The coworker managed to pull her (left) hand out of the press, and pushed down on the safety bar located on the top of the moving platen. However, the moving platen continued closing, trapping the upper left torso, and left shoulder and arm of the Employee #1. The Employer summoned Emergency Medical Services. It took the local Fire Department approximately twenty minutes to extricate Employee #1. Who was pronounced dead at the scene. The cause of death has not been ascertained as the Coroner's report was not available at the time of this report. However, the cause of the incident was failure to disconnect the machinery from its source of (electrical) power and to ensure that all parts of machinery stopped completely prior to placing the die. Other contributing factors were: 1) Failure to train the employees in the safe operation procedures for this machine; 2) Failure to provide guards or devices that would have prevented the machine from closing on employees; and 3) Failure to have the two sets of operators' controls interlocked.