Abstract: Employee #1 was a machine operator at a printing establishment whose duties included routine maintenance of the printing equipment. At the time of the accident he was replacing the blade of an industrial paper cutter. A pedal controlled the clamping device that secured the paper as it was being cut. This clamp ran parallel to the blade and was also used to secure the blade while it was being replaced. The process called for Employee #1 to insert two pins into the clamp and unscrew the blade hold-down bolts. The blade then drops onto the pins, whereupon Employee #1 depresses the foot pedal, the clamp drops, and the blade safely falls into a position in which it can be removed from the machine. Employee #1 was slowly releasing the pedal so that the pilot holes in the blade could be aligned with the blade housing. The blade would then slide into a recessed groove at the top of the cutting head. Employee #1 was aligning the blade, and had his left hand on top of the blade to stabilize it when his foot slipped off the pedal and the clamp traveled to the top of its stroke, as it was designed to do. As the top or blunt side of the blade traveled into the blade groove, the top portion of Employee #1's fingers were amputated. A coworker recovered his fingers about an hour later, but the fingertips had to be pried out of the blade groove and could not be reattached.