Abstract: At 6:45 a.m. on April 27, 1998, Employee #1, a press operator helper with 17 years experience, employed by West Bag, Inc., received a serious occupational injury. The employer prints logos on plastic bags, some of which are used to package tortillas. Employee #1 was placing a plastic sheet under the rollers of the rewind unit of Printing Press Number One to prevent powder from falling on the plastic bags that were to be printed. Employee #1 stated that the press and rewind unit were in operation at the time of the accident. The usual procedure was to place the sheet of plastic in position before activating the press, but on this day the press was running. The press operator was working with Employee #1 at the time of the accident. The press operator stated that the press and rewind unit were not running but the roll changer did have power to it. The press operator and the employer's accident investigation report said that Employee #1 and the press operator were clearing a jammed piece of plastic when Employee #1 bumped the roll changer lever with his stomach. The installation and location of the roll changer lever permitted the operation of the roll changer when it was accidentally bumped by Employee #1's stomach. This lever caused the frame that holds the rolls of plastic to move clockwise, pinching Employee #1's head and shoulders between the frame of the press and the frame of the roll changer. Employee #1 spent two days in the County USC Medical Center. His left ear was amputated and he had pains in his shoulders and face. The hospital was able to reattach the lower part of his left ear, but was unable to save the upper part. This resulted in permanent disfigurement.