Abstract: On May 14, 1996, Employee #1 was at a gas well site, supervising a pressure test on blowout preventers (bops). A test plug had been installed in the well head, but below the blowout preventer so that all the pressure is maintained in the bop stack. The well unexpectedly surged, causing the test plug, which had not been properly sealed, to be blown out of the hole. The plug traveled up through the bop stack, struck the rig's blocks, and then struck Employee #1 in the head while he was standing at the top of the rig stairs. He fell down the flight of stairs and suffered internal injuries, from which he later died.