Abstract: At about 3:30 a.m. on March 16, 1993, an employee working on a V & O 35 ton, full-revolution mechanical power press noticed that the left mounting steel block holding the existing barrier guard to the bolster plate had fractured welds, and that the barrier guard had shifted position so that it was receiving impact from the die ram on each cycle. This employee reported the condition to the lead person, who made the decision to remove the existing barrier guard for the remainder of the work shift since maintenance could not get to the site to repair the guard, and production would be otherwise impaired. At approximately 6:18 a.m., just prior to the end of the night shift, Employee #1, an experienced press production operator, and a member of a work station team, inserted part #04,an arm rail for a high chair product, into the press's point of operation with her right index finger riding atop the part. She activated the press cycle with the foot pedal and half of the first phalange of her right index finger was amputated in the die impact zone. The employee was obviously unaware and certainly had not been warned that the guard had been removed. She had not been working in the area until near the end of the shift, when she came over to help out the team.