Abstract: Employee #1 was employed as a machine operator at a large printing press. At the time of the accident he was attempting to adjust an ink felt, located inches away from in-running rolls, while the machine was running. The wrench that he was using slipped, causing his hand to move into the in-running rolls. Coworkers shut off the machine after they heard Employee #1 yelling and released the rolls to remove him. First aid was administered and Employee #1 was then transported to the hospital by ambulance. His injuries consisted of lacerations and crushed bones. Approximately 2 1/2 weeks after the accident one injured finger was surgically amputated. Contributing factors to the accident were violation of lockout/tagout procedures and inadequate supervision.