Abstract: At approximately 10:00 a.m. on July 26, 1997, Employee #1, a "jogger" with 5 months of experience, was operating the sheeter on lithographic press #6. He was webbing the press onto the sheeter, a process that involved feeding printed paper through several rollers, including a rotary sheeter that cut the paper at predetermined sizes and stacked the finished product. Employee #1 was reaching with his left hand into the operating sheeter to feed the paper through it when the cutter came down. His left index and middle fingers suffered lacerations and contusions, and the ends of both fingers were amputated. Employee #1 was transported to Spectrum Industrial and then referred to the Western Hand Center. Subsequent investigation found four causes of the accident: (1) Employee #1 was not an experienced operator. (2) The company did not have an effective IIP program in place. During an interview, management and supervisory personnel disagreed on the safest way of webbing up the sheeter. While management argued that webbing procedures could best be accomplished with the sheeter off, supervisory personnel said the sheeter had to be on. (3) There was no written procedure on how to perform webbing operations, and different operators were doing this task his/her own way. Employee #1 stated that, after the accident, coworkers told him that he was webbing the wrong way and that it was safer to do it with the sheeter off. (4) The sheeter cutter was not guarded. The guarding of this sheeter had been discussed during a safety committee meeting on April 14, 1997, more than 3 months before the accident, but management had failed to take any corrective action.