Abstract: At 3:45 p.m. on June3, 2016, Employees #1 and #2 were changing out a 10,000 PSI hydraulic cylinder which was leaking. The ram malfunctioned when the new cylinder was put into place and Employees #1 and #2 filled the hydraulic pump system with fluid, believing the problem to be low fluid levels. The ram continued to malfunction and both employees decided to replace the check valve fittings on the cylinder. They retrieved the fittings from the leaking cylinder and, as Employee #1 removed the front check valve from the new cylinder, it flew off and struck him in the face. Employee #1 was killed instantly.