Abstract: EMPLOYEE #1, A DIE REPAIR TRAINEE FOR APPROXIMATELY SEVEN MONTHS, WAS RESPONSIBLE FOR THE MAINTENANCE OF DIE CASTING MACHINE DIES AND TRIM TOOLING UNDER THE DIRECTION OF THE TOOL ROOM MANAGER. EMPLOYEE #1 APPROACHED THE EX-CELLO CORPORATION B & T COLD CHAMBER DIE CASTING MACHINE #5 (MODEL 700CC) WITH INSTRUCTIONS TO POLISH THE UPPER CORNER OF THE DIE ON THE HELPER'S SIDE, DUE TO A PORT QUALITY CONTROL PROBLEM. THE PROBLEM WAS DISCOVERED BY THE COMPANY'S INSPECTOR AND RELAYED TO EMPLOYEE #1 THROUGH THE TOOL ROOM MANAGER. THE MACHINE OPERATOR OF B & T #5 STATED THAT EMPLOYEE #1 TOLD HIM TO SHUT DOWN THE MACHINE. HE DID SO BY PRESSING THE MOTOR STOP BUTTON ON THE CONTROL PANEL. EMPLOYEE #1 THEN PROCEEDED TO STEP BETWEEN THE DIES, FROM THE OPERATOR'S SIDE, TO BEGIN POLISHING. AS EMPLOYEE #1 WAS MOVING IN BETWEEN THE DIES, THE MACHINE OPERATOR STATED THAT HE NOTICED THE AUTOMATIC LADLE ON THE MACHINE WAS ABOUT TO POUR A "SHOT" OF MOLTEN METAL INTO THE PLUNGER. THE MACHINE OPERATOR STATED THAT HE TOLD EMPLOYEE #1 TO "HOLD ON FOR A MINUTE", BUT APPARENTLY EMPLOYEE #1 DIDN'T HEAR HIM OR JUST IGNORED HIM, AND CONTINUED TO CLIMB INTO THE MACHINE BETWEEN THE DIES. THE MACHINE OPERATOR THEN STARTED THE MACHINE IN AN ATTEMPT TO MANUALLY DUMP THE MOLTEN ALUMINUM THE AUTOMATIC LADLE BEFORE IT FROZE. AS THE OPERATOR WAS ATTEMPTING THE DUMP, THE MACHINE PARTIALLY CYCLED. EMPLOYEE #1 WAS CAUGHT AND CRUSHED BETWEEN THE DIES. HE EXPERIENCED SEVERE BURNS TO THE ARMS AND HIS DIAPHRAM, SPLEEN AND LIVER WERE CRUSHED WITH SEVERE INTERNAL BLEEDING. THE MACHINE WAS NOT LOCKED OUT AT THE MAIN POWER DISCONNECT, NOR WAS A SAFETY BAR INSTALLED BETWEEN THE DIES WHILE EMPLOYEE #1 WAS WORKING THERE. LOCK OUT OF THE DIE CASTING MACHINES WAS NOT STANDARD PRACTICE AT THE PLANT FOR POLISHING OPERATIONS, BUT SAFETY BARS ARE SUPPOSED TO BE USED.