Abstract: At 8:15 a.m. on September 26, 1998, Employee #1 and a coworker were on the top deck above the rudder room of ship #134, preparing to weld some metal work at the stern. Simultaneously, coworkers were conducting an air pressure test of the approximately 30 ft long by 4 1/2 ft deep by 4 ft wide rudder room, a common procedure for boats undergoing construction or repair at the facility. Air at 2 psi was used to fill the room so that adjacent compartments and tanks could be tested for leaks at the walls and seams. Employee #1 and the coworker were very close to a 20 in. diameter metal hatch cover that was secured by a 3/4 in. diameter bolt into a camelback underneath the cover. As the pressure began to build inside the rudder room, a weak weld on one leg of the camelback failed and the bolt gave way. The metal cover blew off and struck Employee #1 in the face and chest, knocking from the stern of the ship. He fell approximately 20 ft to the ground and was killed. There were no written procedures governing the air pressure testing, and the procedure was learned through on-the-job training. There had been no injuries as a result of similar tests held previously in the shipyard.