Abstract: At approximately 1:50 p.m. on November 15, 1994, the staff at a refinery set up a training fire drill on its grounds that was attended by an emergency response team. Employee #1 was laying a 3 in. supply hose that was connected by a foam trailer to a fire hydrant. The hose also connected to a gated Y-valve, and a smaller hose was attached to the other side of the value. Once the supply hose was set, Employee #1 gave the signal to fill it. He was struck by the hose and valve as they filled, suffering a fractured leg. The hose arrangement may have opened the Y-valve, which was then thrust upward by the force of escaping water. Witnesses, who were observing the fire drill, said that no device locked the Y-valve closed; the closed handles could be swung open with little to moderate force. The employer was cited for two general and two serious violations.