An experienced press operator was killed when he was struck by pieces of a die thrown from his press.

It appeared that the overhead ram of the press was set an inch lower than it should have been for the size of the die. He somehow accidentally triggered the press and the ram came down and smashed the die.

The fatality report indicated that the worker had a long history of alcohol abuse, and had been taking several medications for chronic illnesses. Tests after his death showed that his system contained alcohol as well as three other drugs. The report also recommended that drug and alcohol programs be set up, and that communication should improve within the plant.