Abstract: On July 27, 2004, Employee #1, a fill station operator, was filling a diving cylinder (SCUBA tank) with 98-percent oxygen. After picking up the cylinder and connecting the oxygen filling hose to it, she then apparently lost her grip on the cylinder, and dropped it onto the concrete floor. The cylinder ruptured at the neck/thread area, and a piece of the cylinder struck her abdomen and knocked her backwards about 10 ft. Employee #1 sustained numerous lacerations and fractures, and died while being transported to a hospital. The cylinder was manufactured by Luxfer Gas Cylinders, constructed of Aluminum Alloy 6061, and engineered to hold 30 cubic feet of gas at a pressure of up to 3,000 pounds per square inch. The cylinder was labeled "oxygen", had a visual inspection certification sticker, dated June 2004, and had an oxygen preparation certification sticker, dated June 2004. The hydrostatic test date was determined to be September 2002.