Abstract: On March 12, 2003, Employee#1 and a coworker were adjusting the dies on a Bradbury Roll Former, while standing on top of the roll former, straddling the rolls. This was done by turning the die shafts until a hex nut was visible then loosening the nut, prying the dies to the side and then tightening the nut. Both employees had bypassed existing safety guards by going to the end, where the sheet metal was fed from and climbing onto the stock table and walking down the length of the roll former. They were using a jog/inch button on a pendent to rotate the die shafts to get to the hex nut. If they removed a guard, the roll former would not have operated. This job was normally done 2 to 3 times a year, and this was the regular method for doing this job. Both employees had assumed that the sheet metal product had cleared the last set of dies and that no more sheet metal was in the roll former. However, Employee #1 was struck in his left leg by a section of sheet metal that had still been in the roll former. His coworker had been using the jog button to turn the die shafts. The sheet metal cut into Employee #1's leg, down to the bone and then broke the bone. His coworker stopped and backed off the sheet metal when he heard Employee #1 scream. Employee #1 was transported to Baltimore Shock Trauma hospital, where he was admitted and underwent surgery to repair his bone, muscles, and ligaments.