Abstract: At approximately 10:00 p.m. on September 28, 1992, Employee #1, of the Sutta Company, was baling waste paper alone at the California State Printing Office in Sacramento, CA. Employee #1 was operating a vertical baler with a platform built about 6 ft off the floor to the level of the feed entrance. Bins of paper were dumped into the baler using hands, feet, and/or a broom. The baler was filled with loose waste paper and the compaction cycle was activated, with the compaction ram coming down. Employee #1 tried kicking a little more waste paper into the compactor but caught his right leg. Because the baler was full, his leg was not fully pulled into the baler, but, because the baler was full, the controls were sent to the tie position. This position stops the ram when it reaches the bottom of the cycle and holds the compacted bale until baling straps are attached. The compaction ram did not recycle back to the top from the bottom of the stroke, keeping Employee #1 pinned in the baler. A night shift coworker, who had been waiting to come on duty, and a state printing coworker heard Employee #1's screams for help and responded. They found Employee #1 with his right leg caught in the baler with the ram down. Emergency services were called and responded very quickly. The Sutta Company site supervisor was called to get information on the workings of the baler. Paramedics and fire department personnel worked for almost an hour and a half trying to extricate Employee #1 from the baler. But his vital signs became irregular, necessitating the amputation of the foot just above the ankle. Employee #1 was taken by ambulance to the University of California Medical Center in Sacramento. His foot was removed from the baler shortly after and also taken to the hospital. Reattachment was not possible due to extensive bone and tissue damage. The baler was found to have been tampered with, in that the cover door interlock had been tied back to allow the ram to operate with the cover door open, a very common and serious problem. Sutta management knew of the hazard and had not only conducted training on the use of the baler with the door open but also used the baler that way themselves.