Abstract: At approximately 7:30 a.m. on December 4, 2000, Employee #1, a novice litho press operator, fractured his right foot when a cassette fell from the press machine. His employer manufactures packaging materials, both paper based and plastics, for frozen desserts and other food materials. The process involved are printing (litho and flexo) and forming. The incident occurred in the litho press room where lithography/wet offset printing was done. The press machine used was a Station Number 2 by Komori Chambon with cassette having Model Number FT 738-23. At the time of the incident, Employee #1, together with another operator, was adjusting the instrument to zero to put the cassette into registration. The cassette, weighing about 600 to 1,000 pounds, fell on his right foot when he tried to zero adjust the cassette by shaking the unit. (Employees stated that it is a normal procedure for them to shake the unit when machine cannot zero by itself. Shaking the unit helps to zero adjust the unit). The cassette sits on a rail with its two wheels suspended on it. During the process of shaking, the wheels of the cassette slipped off the rail, and the cassette fell on Employee #1's right foot. Upon further investigation, it was determined that the incident was caused by a failure to block the rail where the wheel of the cassette is suspended during the zero adjustment process. Employee #1 was taken to USC Medical Center and later transported (per wife's request) to Presbyterian Intercommunity Hospital, where he was treated for severe laceration and fractures of the second, third and fourth toe of his right foot. He stayed in the hospital for 15 days.