Abstract: Employee #1, an electrician, was one of three employees who were troubleshooting a piece of equipment on a furnace roof. The 35 megawatt furnace, used in the smelting of phosphate ore, had been down for a complete rebuild. It had only been brought back up to full load that morning and was running rough. Employee #1, without the furnace operator's knowledge, was standing on a ladder approximately 13 feet away, directly in front of a 9 inch diameter rod out hole on the furnace offtake. The hole is packed with a ball of "clay." Without warning, and as the result of one of a number of possible causes, the furnace went "on pressure". This sudden overpressurization blew out the packing ball. What witnesses describe as looking like the flame of a blow torch engulfed Employee #1 for approximately 20 seconds until the furnace was shut off. Employee #1 sustained third-degree burns that covered 40 percent of his body and died of complications two weeks later. Employee #1 was acting with no written rules or policies for guidance,