Abstract: Employee #1 was performing maintenance work on equipment used to make ignition caps for automotive air bags. He ran into some problems and called maintenance, but instead of waiting for them to arrive, he dismantled and attempted to reassemble the parts. In the process, he put in a part upside down. The part had four screws, and while two of them were still able to be installed, the other two no longer matched with their holes. Unaware that the part was upside down, Employee #1 tried to force one of the screws in at an angle. The friction resulting from this effort ignited the cap's residual explosive material. Flames flashed up the sleeve of Employee #1's smock and he sustained third-degree burns to his arm. Employee #1 was not authorized to perform maintenance work.