Abstract: At approximately 11:00 a.m. on September 11, 2012, Employee #1, a metal fabricator, was installing an upper die on a DiAcro 35-ton press brake, Model Number 1472, Serial Number 6601079533. Employee #1 used his left hand to support the die's bottom while his right hand slid the die along the tongue rail into position. In an attempt to raise the ram so the new upper die would clear the lower die, Employee #1 stepped on the foot control, initiating a down stroke and crushed four fingers on his left hand. Employee #1 was hospitalized. Upon further investigation, it was determined the point of operation was improperly guarded and the employers procedures for changing dies did not provide a requirement to deenergize the machine.