Abstract: At 3:30 p.m. on October 30, 2021, an employee was working for a commercial printer. The firm printed a weekly publication that consisted of advertising. The employee was operating a Web Leader printing press, serial number 61=136. She was at the station of the press where the paper was folded and cut. She was feeding paper into the folder on the press. The folder folded the newspaper and then cut it. The paper came off the pins on the roller of the press. The employee was pushing the paper back onto the moving roll, when her fingers came into contact with the knives. She suffered the amputation of the tips of the three middle fingers on her right hand. She was hospitalized. During employee and management interviews, it was established that the printing process occurred only approximately for four hours per day for two to three days per week. On those days, though, the paper came off the pins and out of the groove and needed to be reattached at least once per day and often several times per day. This task was performed while the folder was still running to keep tension on the roller. By the time of the inspection, the company had not performed an accident investigation or made any changes to the equipment, guarding, or use of hand tools. The company felt that since an employee would have to reach far under the roller to access the knives, no corrective action was necessary. The opening was large enough for employees to reach their arms, hands, and torso into the area while the equipment was running. The opening could easily be guarded to have a smaller opening that only allowed for a hand tool to be inserted into the opening to reattach the paper onto the roller pins and groove. The company did not report the amputation until October 25, 2021. The company knew of the amputation on the day that it occurred, because someone from the company had taken one of the fingertips to the hospital to try to have it reattached.