Abstract: On July 23, 2008, Employee #1, a die setter, was moving a bolster into a transfer press. This bolster was 24-ft long, 15.5-ft wide, and 6-ft high with die installed. The bolster was pneumatically driven. A pendant with two levers was used to actuate movement of the bolster. The bolster would only move in the direction the control levers were set in, one direction at a time, north or south. The employee went between the bolster to be moved and another bolster, where the pendant control was located. He actuated a control but nothing happened. He put the pendant down and went back between the two bolsters to turn the air on. When he did this, the bolster moved and pinned him against the other bolster. Employee #1 was killed. The two levers on the pendant were not guarded against accidental activation.