Abstract: Employee #1 was on the job (2nd shift) operating an aluminum die casting machine. Employee #2 was operating a trim press with his back towards the die casting machine and furnace. The die casting machine had been at the plant about a year and had been used regularly. About 10 minutes into the shift, Employee #1 opened a valve that he may have thought speeded up the shot cylinder. Instead, it activated the intensifier, or booster cylinder, on top of the shot cylinder. When it was activated, a 1 inch diameter shaft extended from it and sheared a straight hydraulic fitting/hose. The hose sprayed hydraulic oil onto both employees and onto the furnace, which ignited the hydraulic oil on the machine and on the two employees. Employees #1 and #2 were severely burned; Employee #1 died. The straight fitting was the wrong fitting; the machine could never have operated using it. At some undetermined time an elbow fitting had been removed and this straight fitting installed. It was just an accident waiting to happen as soon as the intensifier was activated.