Abstract: At approximately 3:20 p.m. on September 23, 2006, Employee #1 was attempting to light a propane-gas-fueled turkey leg roaster with a long-handled lighter. The roaster had been custom built by a local heating and air conditioning contractor and used a water heater control module for burner control. Employee #1 activated the pilot primer valve, which emits propane gas from the pilot located in the center of the main burner. He held the valve open, which allowed propane to build up within the base of the roaster. Employee #1 then tried unsuccessfully to reach the pilot through a small hole in the front of the unit. The accumulated gas reached the flame of the lighter and ignited. Employee #1 was hospitalized with first- and second-degree burns on his left hand, arm, and head. The roaster had no manufacturer's data and there were no written instructions for its use. The normal lighting procedure requires an employee to reach into the roaster through the oven area, where the burner is easily accessible, rather than through the hole Employee #1 attempted to use. The investigation revealed that Employee #1 was not trained in this normal lighting procedure.