Abstract: On Thursday, October 14, 1993, Employee #1, of Cal Central Press, Sacramento, CA, was seriously injured while operating a Web printing press. He had noticed a problem with the press while it was operating in the make-ready mode (a slow-down, setup mode). He knew that the problem was in the lower section of the third unit, which prints with red ink, and suspected that the damper tray was dry. When Employee #1 placed his hand into the water-tray area, his fingers were drawn into the runs above and then between the pan roll and chrome roller. Employee #1 yanked his fingers from the rolls. One fingertip was crushed; the other fingers suffered tendon and possible nerve damage from being pulled back out of the rollers. First aid was administered to Employee #1, who was then transported to Sutter Memorial Hospital in Sacramento. He was treated and released after the tip of one finger on his left hand was amputated.