Abstract: On September 22, 2008, Employee #1, a sheet metal worker, was setting up a Verson mechanically driven 35 ton press brake for change in production. He was measuring the distance to the stop block with his right hand, holding the end of a metal tape measure in the middle of the point of operation, when he actuated the treadle causing the press to cycle. The upper die did not complete the cycle and became bound by his gloved hand. The guarding on the rear of the press had to be removed to access the equalizer shaft to counter rotate it to raise the die, to free the employee's hand. It took approximately twenty minutes to free his hand. As a result, the three fingers on his right hand were amputated. Employee #1 was hospitalized. The employer appears to have a well devised safety program and adequate lockout procedures; however, they don't seem to be followed as a matter of pattern and practice.