Abstract: A pallet of paper containing 5000 to 7500 sheets and weighing 4500 pounds had been printed with labels on a 77-in. Miehle offset press. The pallet was on a 2-in. by 66.5-in. by 97.5-in. steel plate, weighing 500 to 1000 pounds. The pallet plate was held by chains and lowered by an electric hoist into a 2-in. depression in the floor so that the plate was level with the floor and so that the pallet of paper could be taken out with a handtruck. As one employee lowered the material slowly using the controls on other side of press, Employee #1 stood on the floor with his hands up holding the paper straight on top of the pallet. He inadvertently placed his left foot over the edge of the depression in the floor. The employee at the controls could not see Employee #1's feet. The pallet came down on Employee #1's left foot, amputating three toes and partially amputating a fourth. The plate came down slowly but the injured employee was unable to react in time to prevent injury. Employee #1 had worked for this company only 2.5 months and had worked on this job only 2 weeks. There was no prescribed procedure for lowering the pallet. A runway to guard the floor depression was available, but its use was not required. Employees received on-the-job training with one helper training another.