Abstract: At approximately 10:00 a.m. on January 25, 1993, Employee #1 removed the metal cover from the back side of a running printing press to adjust the feed-tapes to print a smaller size paper. As he reached under the machine, the gear caught his shirt sleeve and pulled his left arm into the chain driven sprocket. He sustained a skin avulsion of about 1 1/2 in. diameter below his elbow, and was hospitalized. Employee #1 said that he was about to take his morning break and that he had done this adjustment while the machine was running every seven months for the last four years. On the day of the accident, he was wearing a longer shirt sleeve and it snagged on the lower sprocket. Management said that Employee #1 had been properly trained by an outside consultant and had more than four years of experience. The supervisor said that he had never trained or instructed Employee #1 to remove the guard to make the running adjustment. The printing press was functioning properly. The employer was cited for violation of T8CCR and a serious citation was issued with penalty.