Abstract: On September 27, 2001, Employee #1 was attempting to handle an 1,100 R20 truck tire encased in a vulcanization envelope that had been overfilled with compressed air. Target air pressure was 10 p.s.i. to hold tire shape. However, the air hose remained connected to the tire and inflated the tire to near 145 p.s.i. Then, the tire exploded, shattering the vulcanization rim. The blast and fragments struck Employee #1's chest, neck and head and hurled Employee #1 about 16 feet, killing him. He also had three broken ribs. Forensic examination of the air pressure regulator revealed the device was installed in a reverse condition and regulator function was not functioning. Maximum air pressure was delivered at all times through the regulator regardless of the T-handle setting.