Abstract: At approximately 8:30 a.m. on August 30, 1991, Employee #1 was preparing to tint ophthalmic lenses using dye pots warmed in a temporary oil bath set-up. The oil bath was not heated by an electric coil in the bath (as usual), but with a two-burner electric hot plate. Employee #1 was pouring acetone, to be used to clean the lenses prior to tinting, into a metal pan on the bench near the temporary oil bath set-up. The acetone ignited and created a fireball that engulfed Employee #1. He suffered smoke inhalation and first-, second-, and third-degree burns over approximately 42 percent of his body. Employee #1 died of adult respiratory distress syndrome on September 22, 1991, at approximately 2:49 a.m.