Abstract: At 3:15 p.m. on July 11, 2019, Employee #1, a boilermaker, and two coworkers, employed by a refractory services company, were working at a multiemployer construction project, a refinery's tank farm. They were performing maintenance and repairs to a tank's interior floating roof and bottom. They made use of an employed-designed and fabricated jack stand to lift the floating roof inside the tank. The jack stand, which had not been designed to withstand the forces involved in lifting the floating roof, broke. The jack stand's metal top plate, which measured 24 inches by 24 inches and weighed approximately 50 pounds, struck Employee #1's face. Employee #1 sustained traumatic injuries to his face and was killed. The subsequent investigation determined that the employees had not been trained to use the lifting system. In addition, there were no employer records of employees having been trained to work in permit-required confined spaces or environments where exposure to heat-related illness could be reasonably anticipated, such as the interior of the tank where they were working when Employee #1 was killed.