Abstract: At approximately 10:15 a.m. On August 18, 1989, Employee #1 initiated the first-trip cycle leakage on a press because it failed to trip the previous week. Maintenance help was brought in from one of the company's outside contracting companies to perform maintenance on the press. The next morning on the first cycle, Employee #1 initiated his press directly into continuous mode. Employee #1 began moving the die slide forward toward him while sitting on a stool. The repeated motion of the lap of the operator caused the die slide to blast right through two safety stops and lacerates Employee #1's penis. Employee #1 was treated and sent back to work within an hour. Teflon tape had been placed in the exhaust part on the clutch control valve, overriding all electrical systems and the single-stroke mechanism the press.