Abstract: Employee #1 and coworkers were removing a die from a mechanical press but the hydraulic component on the die did not release. Using the press to load the hydraulic component to get it to release and, at the same time, trying to reattach the hydraulic lines, caused the piping to burst. Employee #1 was struck in the leg by a large piece of the piping. He suffered a fracture and dislocations. Employee #1 later died in the hospital of a blood clot and complications. The press was rarely used. This was the first production run after several trials. The pressure from the press was more than the rated loading and no pressure release valve was installed in the high pressure chamber. Lockout or proper die setting procedures might have prevented the accident.