Abstract: At approximately 9:30 p.m. on March 15, 2000, Employees #1 through #3 were on a production line filling and packaging 20 lb propane gas cylinders for shipment. Employee #1 was placing the empty cylinders on a Plant Systems Incorporated (PSI) carousel and connecting the fill hose to each cylinder. The carousel then rotated the cylinders clockwise around the servicing area approximately 270 degrees, at which point Employee #2 would disconnect the filled tank and place it on a conveyor next to the carousel. Employee #3 would take the cylinders from the conveyor and place them on wooden pallets for shrink-wrapping and shipping. Employee #1 was preparing to fill an empty cylinder by connecting the fill hose and opening the cylinder's fill valve. He was reaching to press the FILL button on the control panel of the carousel when a flash fire occurred. Employees #1 and #2 sustained first- and second-degree burns to their faces and were admitted to Baptist Hospital Burn Center in Winston-Salem, NC. Employee #3 suffered minor facial burns and singed hair; he was treated and released. During subsequent investigation, it was determined that the company did not have any dress requirements, nor did any governing standard establish what employees should or should not wear while working at or near the carousel. Employee #1 was wearing all-cotton clothing with the exception of an overshirt that he was using as a jacket. The overshirt was composed of a 100 percent cotton shell, a 100 percent nylon lining, and a 100 percent polyester fiber filling. The synthetic materials used in the lining and filling were static producing materials and could have caused or increased the risk of sparks from static electricity. Further investigation revealed that there was no requirement to ground/bond the propane cylinders or the fill guns used to fill the cylinders. The following references supported this finding: OSHA standards 1910.110(b)(17)(iv); NFPA 58, 3-7.1 application. 3-7.1.3; NFPA 58, 4-1.1 application. 4-1.1.1 and 4-1.1.2; and NFPA 77, 6-1.3.