Abstract: On October 15, 2001, Employee #1, a lidman at a coke operation, was charging coke ovens. He and a larry car operator had just charged the #15 oven, after which the coworker moved the larry car away. Employee #1 was apparently sweeping coal into the #15 oven when he stepped backward onto the lid of the charge hole of the #14 oven. It flipped up and caused his right foot and leg to plunge into the charge hole. The oven gases ignited and burned his leg, torso, face, and arms. The coworker reportedly heard a pop and went around to the opposite side of the car, saw a large plume of smoke and fire, and then saw Employee #1's hand and arm reach out of the fire. The coworker pulled him out of the charge hole, whereupon Employee #1, with his clothing on fire, started to run. The coworker knocked him down and rolled on him and on the oven to put out the fire. He then rushed Employee #1 to the doghouse shanty, where he removed his clothes, doused him with water, and then went for help. Employee #1 sustained third-degree burns over approximately 60 percent of his body and was transported to Southern Ohio Medical Center, where he was stabilized. Employee #1 was then airlifted to the University of Cincinnati Medical Center Burn Unit, where he died 6 days later. The coworker later stated that he thought Employee #1 had been burning in the charge hole for approximately 30 seconds.