Abstract: On December 23, 2003, Employee #1, a rig hand, and coworkers were conducting a top/surface cementing job. The cement line from the pump truck was positioned across the rig floor to the well casing and was not secured to prevent movement. While pumping the cement, within seconds, there was a sudden and drastic rise in pressure, increasing from 50 psi to 800 psi. In turn, the rate at which the cement was being pumped doubled, going from 4 barrels per minute (bpm) to 8 bpm. The cement line and 6-foot stinger, positioned between the well casing and conductor pipe, began to whip around. Employee #1 was struck in the head and knocked through an open and unguarded V-door and off the rig floor approximately 30 feet to the ground. Employee #1 died.