Abstract: Several operators were preparing to ignite a 2-B-3 crude heater after a two week turnaround. The lead operator had two very inexperienced workers helping him light the heater. Due to the lack of precise and clearly written procedures and proper training, a large concentration of fuel gas was allowed to enter the heater before the pilot light was ignited. The resulting explosion killed Employee #1, who received fatal injuries to the back of his head. The operators bypassed safety shutdown features and did not do a visual check of the emergency shutdown system to ensure that the features were closed. In addition, they did not check the firebox to ensure that it was gas-free before lighting the heater.