Abstract: Employee #1 had removed the guard from a press in order to make adjustments to the press. When the adjustments were complete he did not replace the guard before starting the press, which is run by a jog switch when the guard is off. Shortly after, Employee #1 was adjusting the ink flow to the press and slipped and fell into the press where the guard should have been. Employee #1 was as far from the safety shut off switch as he could be but was still able to reach the switch, thus saving his own life. It took about two hours to partially dismantle the press and remove Employee #1. Employee #1 sustained broken right fingertips, a broken tendon on the right thumb, and tissue displacement of the right forearm. He underwent surgery for skin grafts, for pins to be placed in each finger, and for his thumb tendon to be reconnected. Further surgery may be necessary. Not replacing the guards after they had been removed had become a common practice.