Abstract: At approximately 10:30 a.m. on November 15, 1990, Employee #1, a trainee, and a coworker, a refueler, both of Butler Aviation, were refueling a small aircraft using a refueling truck that had a leak at the coupling between the filter and the meter on the pumping station. Employee #1 was left alone to use the truck and inhaled the leaking aviation fuel. He died of circulatory collapse after inhaling the fuel. Employee #1 had been working at this job for less than four days; it was against company policy to allow him to work alone so soon. In addition, company policy stated that all refueling trucks were to be checked for leaks on each shift, and that any leak must be repaired immediately.