Abstract: On February 23, 2003, Employee #1 was operating a small power press used to join two connections together. After the press completed a stroke, he reached into the die to retrieve the part. He stated in an interview that he heard an unusual sound and then the top plate of the ram, which weighs approximately 400 pounds, fell down to the die. He attempted to get his hands out from the die area, but the falling top plate pinned and amputated his fingers on his left hand. Inspection of the press revealed that threads from the place where the top plate attached to the activation rod were stripped and pulled out from the bore, suggesting area of failure. The press was built especially for the employer and is referred to only as Pie Press Cruncher Number 903. The press was guarded by a light curtain and a two hand trip activation mechanism. Other employees performing similar duties at the time of the inspection were observed blocking out the die between strokes. Interviews of the employees revealed that this was a normal and customary practice. Employee #1 was taken to a local hospital.