Abstract: Employee #1 was operating a full-revolution Niagra power press. She had run approximately 36 parts through the press when she reached into the point of operation to remove a part. The press brake failed and the ram drifted down onto her left middle and index fingers, fracturing both. She was hospitalized. All safety features, two-hand trip, barrier guards, and light curtain were operable. Upon investigation it was found that the brake cylinder had dust on it and after taking the cylinder apart a burr was found on the shaft inside. Evidence indicated the dust and burr made the brake sluggish which allowed the roll over to occur.