Abstract: At approximately 2:20 a.m. on April 14, 1991, Employee #1 was working on the unit #1 newspaper folding machine. He was re-feeding three sheets of paper into the machine. A misfeed normally occurs 6 to 8 times a night. Employee #1 put the press on "walk" (slowest speed without jogging) instead of "safe" (lockout). The site was short on staff and Employee #1 was trying to do too much. His long shirt sleeve got caught in the folding machine and his hand was drawn into its rollers and crushed. At the hospital, Employee #1's middle finger on his left hand was completely amputated. The index finger has an infection and may also be amputated. Employee #1 has been hospitalized for 35 days and has had four operations.