Abstract: On May 19, 1984, Employee #1, a machine operator working 3rd shift, was operating a Niagara #35, A-35 punch press, serial #41461, tonnage 35, stroke 2. She was punching cut saw blades to reduce their width. The press has an Airgard type A device, a hard plastic door approximately 7 in. in front of the point of operation. The sides of the point of operation are protected by metal bars. The press has two foot pedals; employees place the cut saw blade on the die with the right hand and press the left foot pedal, then a small device holds the blade in place. Then the right foot pedal is depressed; the Airgard door will come down to its rest position 1/2 in. from the machine's work base, then the press will actuate and return to its rest position. All of this must happen before the Airgard door will rise and clear the way for employees to remove the punched materials with their left hand. If the Airgard door is interrupted in its travel to its rest position, the press will not actuate. Employee #1 had received approximately 3 months on-the-job-training on this press and currently has approximately 5 years experience. The press operated normally but, once while Employee #1 was removing a finished blade, the press actuated without any other part of the machine functioning. Her left index finger was partially amputated and two others were abraded. Management engineers and manufacturer's representatives could not isolate a problem, nor cause the press to operate in the same fashion as it had on the day of the accident.