Abstract: At 12 noon on November 26, 1997, Employee #1, of Imperial Die Cutting, was assisting the operator of a Heidelberg letter press because the paper was not dropping in the correct position in the dies. After observing the situation for several cycles, Employee #1 reached into the die area to check the location of the paper before it dropped and the dies closed. The two workers did not coordinate their efforts and the operator continued to jog the machine not realizing the Employee #1's right hand was inside. The dies closed upon his fingers with a force of approximately 3,000 lb per square in. and a closing gap of less than 4 in. The ring on this fourth finger was crushed almost flat and twisted, nearly amputating the finger; two other fingers were broken into fragments, with nerve and tendon damage. Employee #1 was driven to a local medical clinic and then referred to Mercy Hospital, where he was admitted for treatment. Subsequent investigation revealed that there were many parts of the press machines that were not adequately guarded by the manufacturer or by the employer.