Abstract: On July 19, 2001, Employee #1 was torch soldering piping leading to a tank when there was a flash fire. The tank had not been marked with its contents or a warning. It had not been fully drained of a flammable methanol and water solution, had not been flushed or purged, and had not been tested for flammability prior to the soldering. Management had not followed the required procedures or its own written line breaking, hot work permit, and safety work permit procedures. Employee #1 was set on fire and suffered second and third degree burns to his face, neck, arms, abdomen and back. He was treated at a hospital and was sent home the next day, where he was incapacitated for an additional twelve days.