Abstract: At 5:30 p.m. on May 7, 1984, during the night shift, Employee #1, a press operator, was running Monarch letterheads on press #8, which is an A B Dick offset 350 printing press, serial #00255. Noting that the letterheads were not coming off the press straight enough, she went to the back of the press where the letterheads were being ejected off the impression cylinder by the two ejector wheels. With the press still running, she began to adjust the right ejector wheel with her left hand. Her left index finger and thumb moved into the press and were caught in the opening of the impression cylinder. The cylinder has an outside circumference of approximately 21 in. and the opening comprises approximately 15 percent of its surface. The cylinder is set back into the frame of the press approximately 9 1/2 in. The back of the press is approximately 32 1/2 in. above the floor and the impression cylinder is approximately 14 in. in length. Employee #1 sustained a laceration to her left index finger and contusions to the index finger, thumb, and knuckles. Press #8 is one of four rebuilt presses the company has received and placed into operation within the last 2 months. The back portion of these presses is not guarded. The rest of the offset presses that the company owns are guarded in this area by an interlocking door which, when opened, automatically shuts off the press. It is the company's policy that employees must turn off the press whenever having to make adjustments or, for any reason, place their hand into the press. This procedure is not in writing and is only enforced verbally. The company provides on-the-job training for new employees. They are trained by the supervisor and experienced employees for 2 to 3 weeks. Follow-ups are conducted by the supervisor after the initial training period.