Abstract: At 4:00 a.m. on April 30, 1997, Employee #1, a press room manager, began work operating a Miehel Products printing press, model 625. He finished up a print run and began setting up the press for a new run when he realized that the 35 in. diameter by 41 in. long roller still had glue on it from the previous run. Rather than follow the proper safety steps and the manufacturer's recommended safety guidelines to remove the glue, Employee #1 put his right hand under the guard. He then put his left hand on the inch/reverse button, unlocked it, and held his finger on it. While the warning alarm was sounding, indicating that the rollers were about to start moving, he put his fingers into the rollers to remove the excess paper and glue. When the rollers started, his fingers became caught and were pulled into the machine. Employee #1's right index and ring fingers were crushed between the rollers, requiring surgical repair and amputation of the tips. The other press operators said that they lock up the inch button to prevent incidents like this, and that Employee #1 should have adhered to the recommended safety steps.