Abstract: On September 7, 2002, an employee, a helper on a Ward two-color printing machine, and the operator of the die cutter were setting up and cleaning the machine. This consisted of changing the print dies and/or the die cut blanket. It also required cleaning the ink from the anilox and the rubber metering rolls, as well as from the ink pan. The employee was bending over to remove the ink pan below the rollers when his left hand became caught in the nip point between the anilox and the rubber rolls. He amputated the first digit of his middle finger, his fourth finger, and his little finger. Although the entry points of the different sections of the die cutter had been locked out, there was no procedure to lock out the machine when the guard was removed from the rolls to permit cleaning.