DATE: 

September 25, 2019

TIME:

12:30 p.m. 

VICTIM:

64-year-old automotive

mechanic

INDUSTRY/NAICS CODE:

Other gasoline 

stations/447190

EMPLOYER: 

Gasoline station with 

service station and snack 

store

SAFETY & TRAINING:

Employer provided limited 

training

SCENE: 

Bay inside repair garage

LOCATION:

Massachusetts

EVENT TYPE:

Explosion

INCIDENT HIGHLIGHTS

REPORT#: 19MA058 REPORT DATE: July 15, 2022

Automotive Mechanic Fatally Burned While 

Using Welder When Washer Fluid Drum 

Explodes —Massachusetts 

SUMMARY

On September 25, 2019, a 64-year-old white non-Hispanic male 

automotive mechanic was injured in an explosion inside a service 

garage. He was welding on top of a nearly empty steel drum of 

flammable washer fluid, which caused the drum to explode. The 

explosion covered him with burning fluid and he died from the burns 

six weeks later. READ THE FULL REPORT> (p.3)

CONTRIBUTING FACTORS

Key contributing factors identified in this investigation include:

• Worksite lacked a proper welding station

• Welding in the vicinity of a drum containing flammable materials

• Lack of a safety and health program and overall safety training

LEARN MORE> (p.9)

RECOMMENDATIONS

Massachusetts FACE investigators concluded that, to help prevent 

similar occurrences, employers should: 

• Provide an appropriate location to perform welding work. All hot

work should be a safe distance away from flammable and

combustible liquids. Ensure workers using welding equipment

are trained in the safe operation of their equipment.

• Ensure that all workers are properly trained about hazardous

materials in the workplace.

• Develop and implement a comprehensive safety and health

program that addresses hazard recognition, avoidance of unsafe

conditions, and proper use of equipment. LEARN MORE> (p.9)

Massachusetts FACE Program
Page 2

Fatality Assessment and Control Evaluation (FACE) Program

The Massachusetts Department of Public Health, in cooperation with the National Institute for Occupational Safety and Health (NIOSH), 

conducts investigations on the causes of work-related fatalities. The goal of this program, known as Massachusetts Fatality Assessment and 

Control Evaluation (Massachusetts FACE) is to prevent future fatal workplace injuries. Massachusetts FACE aims to achieve this goal by 

identifying and studying the risk factors that contribute to workplace fatalities, by recommending intervention strategies, and by disseminating 

prevention information to employers and employees. 

NIOSH funded state-based FACE Programs currently include: California, Kentucky, Louisiana, Massachusetts, Michigan, New York, Oregon, and 

Washington.

Email | Website
REPORT#: 19MA058 Page 3

INTRODUCTION

An automotive mechanic working for a gas station and service garage was severely burned when a drum of flammable 

window washer fluid exploded as he was using the drum as a workbench for welding. The Massachusetts FACE Program 

learned of the incident from the local news media on the day of the incident, September 25, 2019. The Massachusetts 

FACE Program received notification from the Massachusetts Department of Fire Services that the worker had sustained 

burns to an estimated 75% of his body and was being treated at a regional trauma center on September 26, 2019. On 

November 6, 2019, a representative from the Office of the Chief Medical Examiner notified FACE that the worker had 

died from his injuries on November 5, 2019. On December 10, 2019, a representative from the Massachusetts FACE 

Program spoke with the owner of the gas station to discuss the incident. Several records were reviewed during the 

investigation. The records reviewed included local and state police reports; the reports from the state police unit 

assigned to the Office of the State Fire Marshal to investigate fires, explosions, and arson; the electronic death 

registration system; OSHA records; and information from the welder and window washer fluid manufacturers.

EMPLOYER

The employer owned the business and the property where the incident occurred. The property consisted of a gas station 

with a service station and snack shop. The station sold gasoline and diesel fuels and conducted annual state vehicle 

inspections and repairs. The employer operates several other gas or combination gas and service stations in the region, 

including a second service garage in the town where the incident occurred. The employer reported that the station 

where the incident occurred had one manager, three mechanics (including the victim), and a vehicle inspector at the site 

at the time of the incident. At least two other workers were at the site to pump gas and to work on vehicles inside and 

outside of the building. It is believed some of these workers also regularly worked at the employer’s other locations.

The regular work schedule for the manager and site mechanics, including the victim, is not known. The worker who 

conducted vehicle inspections was at the station part-time, for 20 hours each week.

At the time of the incident, the employer had workers’ compensation insurance. As required by Massachusetts law, all 

employers operating in Massachusetts are required to carry workers’ compensation insurance for their employees and 

for themselves if they are an employee of the company. The requirement applies no matter the number of hours 

worked or the number of employees. Employees of this company did not have union representation.

WRITTEN SAFETY PROGRAMS and TRAINING

At the time of the incident, the employer did not have a written comprehensive safety and health program. Workers 

were provided some basic training. Formal training was not provided to employees nor was the training documented. 

The training did not cover welding or hazardous materials. The employer did not have a written hazard communication 

program to train workers about chemicals located and used at the site, and the employer did not maintain copies of the 

safety data sheets (SDS) that describe each manufactured chemical. The SDS must be available at the site for worker

training and followed to ensure safe work practices.

WORKER INFORMATION

The victim was a 64-year-old white non-Hispanic male who had been employed as a mechanic by the employer for 10 

years at the time of the incident. He had worked at the service station since it opened. He had 30 years of previous 

experience as a mechanic working for other employers. 
REPORT#: 19MA058 Page 4

EQUIPMENT

The welder that was involved in this incident was an electric flux core arc welder (Figure 1). It was a portable plug-in unit 

that weighed 46 pounds. It used a specially designed consumable electrode (welding wire) to generate an electrical arc 

and high temperatures in order melt the electrode and fuse it to the piece being welded. The base unit plugged into a 

standard outlet and a transformer in the unit generated a 17-volt direct current charge at up to 88 amperes (Figure 2). 

 

Figure 1 – Flux core arc welder (manufacturer’s site) Figure 2 – Welder specifications, from manual 

The welder had two cables to complete the electrical circuit (Figures 1 and 3). A return cable had a clamp and would be 

attached to the work piece. This provided a pathway for the current to return to the base unit. The hot cable had a 

handle with a trigger switch that controlled a spool drive motor. The motor would push the flux core wire through the 

hot cable and out the tip of the handle. The electrical current would pass through the flux wire when it contacted the 

work piece and melt the flux core wire. Voltage, amperage, and spool/wire feed speed could be adjusted on the base 

unit to optimize the weld and the amount of flux wire used, creating a reliable weld. These settings could be adjusted 

depending on the work piece and the desired weld shape and style. The machine was designed to be able to weld steel 

up to 1/8” thick. 
REPORT#: 19MA058 Page 5

Figure 3 – Flux core art welder cable diagram, from manual

The use of this type of welder in Massachusetts, in this setting, requires that the local fire department be notified to 

inspect and approve the site as safe. If this procedure had been followed, an appropriate location for welding could have 

been identified. An employee properly trained as a welding supervisor would then have the authority to oversee welding 

work without additional permitting. These concepts are discussed further in the recommendations that follow. 

INCIDENT SCENE

The facility (Figures 4 and 5) was in a residential area of town and was on a corner lot on a street that served as one of 

the main east/west routes in the town. The outdoor space is flat and mostly paved with asphalt and concrete. Dozens of 

vehicles were parked around the perimeter of the property. The building had two vehicle service bays, an inspection 

bay, and a snack shop/service office area. The two service bays had overhead doors that faced the gas pumps and 

intersection. The inspection bay was on the back of the building and was accessed from the southern side. This entry 

had an overhead door and there was also an exterior door on the northern side of the inspection bay and an internal 

doorway that connected to the service bays. The incident occurred in the vehicle service bay area. Both service bays had 

vehicle lifts and both bays were in use at the time of the incident. 

 
REPORT#: 19MA058 Page 6

Figure 4 – Gas and service station; the inspection bay entry is visible on this side of the building (image from 

google maps)

Figure 5 – Gas and service station; the incident occurred at the rear of the service bays (image from google 

maps)
REPORT#: 19MA058 Page 7

WEATHER

The weather at the time of the incident was approximately 71 degrees Fahrenheit, 45% humidity, with a 12 miles per 

hour north-northwest wind, and fair skies. [Weather Underground]. The weather is not believed to have been a factor in 

this incident.

INVESTIGATION

On the day of the incident, the victim was helping to repair a car in the left service bay. His time of arrival at the work 

site was not recorded. Other employees were pumping gas, inspecting vehicles in the inspection bay, and working on 

another vehicle parked outside of the building. The victim was working to remove the fuel pump from the car. To 

accomplish the task, he was constructing a special tool using an oil filter wrench and other metal. The employer 

described the production of model-specific tools as “routine” and indicated that this work would sometimes require 

welding custom tools directly onto the auto parts while still installed on the vehicles.

Several steel drums were stored along the rear wall of the service bay. At least one of these drums contained window 

washer fluid concentrate. The 55-gallon drum had two bung holes in the lid. One hole served as a vent and the other 

hole had a hand-operated pump and spigot. The workers used this window washer concentrate and diluted it with water 

for use at the station and to put into bottles for station customers. The drum and pump were supplied by a distributor 

and on the day of the incident the drum was nearly empty. A new drum was scheduled to arrive in the following days. 

The victim set up a temporary welding station on top of the steel drum. As a coworker held the work piece in position 

the victim began to make spot welds to assemble the tool. The coworker was holding the piece with his arm extended 

and was facing away. It is unknown if either worker was using any protective equipment such as a face shield, gloves, 

and non-flammable clothing. The victim made one weld and was proceeding to make a second weld when the drum 

exploded.

The top of the drum blew off and the coworker holding the piece suffered a burned arm and facial trauma. He fled the 

garage as the washer fluid vapors had ignited and the fire began to spread. The victim was covered in burning fluid and 

was on the floor of the garage underneath one of the vehicles. Workers in the inspection bay and who had been working 

outside of the building heard the explosion and gathered outside. They realized the victim was still inside and reentered 

the building to drag him out. They used fire extinguishers to try to put out the flames on his body. His clothing eventually 

burned and was torn away to fully extinguish the flames on his body. 

A resident of a home across the street was outside and heard the explosion and called 911. Several individuals in the 

area who heard the explosion also called 911. These calls went to a regional collaborative call center and were 

dispatched to assets in the town. Police were first to arrive, followed by the fire department and an ambulance 

dispatched from a neighboring jurisdiction. The victim was treated at the scene and driven by ambulance to a nearby 

airport and was flown by helicopter ambulance to a regional level one trauma center. He died six weeks later. 
REPORT#: 19MA058 Page 8

Figure 6 – Garage after the fire was extinguished, from scene footage; drums along back wall are in the 

center of the picture. 

Figure 7 – A drum with hand pump (left) and a drum with missing top, from scene footage.
REPORT#: 19MA058 Page 9

CAUSE OF DEATH 

The medical examiner listed the cause of death as complications of thermal injuries. 

CONTRIBUTING FACTORS 

Occupational injuries and fatalities are often the result of one or more contributing factors or key events in a larger 

sequence of events that ultimately result in the injury or fatality. Massachusetts FACE investigators identified the 

following unrecognized hazards as key contributing factors in this incident:

• Worksite lacked a proper welding station

• Welding in the vicinity of a drum containing flammable materials

• Lack of a safety and health program and overall safety training

RECOMMENDATIONS/DISCUSSION

Recommendation #1: Employers should provide an appropriate location to perform welding work. All hot work should 

be a safe distance away from flammable and combustible liquids. Ensure workers using welding equipment are 

trained in the safe operation of their equipment. 

Discussion: Welding uses electrical current or chemical reaction/combustion to create heat to melt and fuse materials. 

The high temperature, intense light (radiation), sparks, and fumes from the welded materials are hazards that need to 

be considered and controlled. Several agencies regulate the use of welding tools at workplaces. OSHA, NFPA, and state 

fire code all require hot work, including welding work, to be conducted in an appropriate location. It is the employer’s 

responsibility to ensure that the worksite is properly assessed to identify suitable locations to weld. This includes making 

sure the area is free of flammable materials, is ventilated to control fumes, is electrically safe, and that the workers are 

properly equipped with protective glasses or a face shield, appropriate gloves, and nonflammable protective clothing.

For this workplace, applicable regulations include those of the Federal Occupational Safety and Health Administration, 

and in particular OSHA 1910.252, Welding, Cutting and Brazing and 1910.106, Flammable liquids.2 1910.252 prohibits 

use of welding equipment:

In the presence of explosive atmospheres (mixtures of flammable gases, vapors, liquids, or dusts with air), or 

explosive atmospheres that may develop inside uncleaned or improperly prepared tanks or equipment which 

have previously contained such materials, or that may develop in areas with an accumulation of combustible 

dusts.

1910.106 describes proper ways to store flammable liquids in the workplace.

In Massachusetts, the local fire department is required to inspect and issue a permit for any location where welding 

work is to be performed [Department of Fire Services]. This includes fixed locations, like automotive service stations. 

Users of welding equipment are also required to complete training as indicated in the Board of Fire Prevention: 527 CMR 

1 Massachusetts Comprehensive Fire Safety Code. This code references National Fire Protection Association (NFPA) 

2015 Fire Code and Massachusetts state amendments and requires specific training for users and qualified hot work 

supervisors and details the procedures for identifying and obtaining permits for welding locations. These regulations 

were updated to include additional protections and outreach and training initiatives were started at the state level in 

2018 after a non-permitted welding fire in 2014 resulted in the deaths of two municipal firefighters. While the victim of 
REPORT#: 19MA058 Page 10

this welding explosion had experience welding over a 30-year career as a mechanic, it is important and necessary to 

recognize and understand changes to regulations, and it is the employer’s responsibility to ensure workers are trained.

The employer described that the station had a welding area and bench or cart with a vise. Records reviewed indicate 

that this bench was used but also that welding work was performed directly on the vehicles, on the floor, and on top of 

the drums located in the garage. The presence of the flammable fluid containers in the workspace, and the presence of 

other flammable materials throughout the garage should have been identified by the employer and would have been 

identified by the local fire department had a permitting inspection occurred. 

This fatal incident underscores the need to use welding equipment in a safe environment and to follow methods and 

procedures described in the operator’s manual or in applicable regulations. The operator’s manual contained specific 

information that prohibited use of the welder under the circumstances that led to this incident (Figure 8). Specifically, 

the welder should not have been used near flammable material or near closed containers. Appropriate and 

comprehensive training on use of the welder, incorporating the operator’s manual, could have identified these hazards 

and prohibitions.

 

Figure 8 – Safety precautions from operator’s manual
REPORT#: 19MA058 Page 11

Recommendation #2: Employers should ensure that all workers are properly trained about hazardous materials in the 

workplace. 

Discussion: The 55-gallon drum of flammable window washer concentrate that exploded was properly labeled on the 

side and lid with Globally Harmonized System (GHS) pictograms indicating it contained a highly flammable liquid (Figure 

9). It was reported that the employees did not have sufficient training to understand what this labeling meant. The 

Safety Data Sheet (SDS) for the material indicated it was >99% methanol with a balance of blue colorant and had a flash 

point of 11 degrees Celsius (52 degrees Fahrenheit), meaning the fumes escaping the barrel would have combusted in 

the presence of an ignition source.

One of the most cited OSHA standards is 29 CFR 1910.1200 Hazard Communication. This standard describes GHS 

chemical labeling, safe handling, use, and storage of chemicals in the workplace, and training. As described on the OSHA 

hazard Communication topic page: 

All employers with hazardous chemicals in their workplaces must have labels and safety data sheets for their exposed 

workers and train them to handle the chemicals appropriately. 

The employer did not properly train the workers about what chemicals were present at the site, how to store them, how 

to handle them, and how to respond to the fire involving the chemicals. The gas station was constructed at a time when 

station-wide fire suppression systems were not required. The station had four class A-B-C, 25-pound hand-held fire 

extinguishers that had just had their annual inspection. While workers at the station were able to shut off the fuel valves 

for the fuel pumps, all four extinguishers were used to try to put out the flames on the victim. This type of extinguishing 

media would have been effective and appropriate to extinguish the burning washer fluid on the victim. Because of how 

the chemicals were stored in the facility and because of other materials in the garage, the fire was able to spread very 

quickly and ultimately destroyed the building and caused a vehicle adjacent to the building to also catch fire.

It is worth noting that less-flammable and non-flammable window washing products are available. Elimination of the 

flammable products from the worksite by substituting a safer alternative is a preferred method to control this hazard. 

Figure 9 – OSHA GHS flame pictogram for flammable liquid
REPORT#: 19MA058 Page 12

Recommendation #3: Employers should develop and implement a comprehensive safety and health program that 

addresses hazard recognition, avoidance of unsafe conditions, and proper use of equipment. 

Discussion: Having a comprehensive safety and health program is essential to maintaining a safe workplace. A safety and 

health program should include the systematic identification, evaluation, and prevention or control of both general 

workplace hazards and the hazards of specific jobs and tasks. The core elements of an effective safety and health 

program are management leadership, worker participation, hazard identification and assessment, hazard prevention 

and control, education and training, and program evaluation and improvement. The program should outline safe work 

practices workers are expected to adhere to, specific safety protection for all tasks workers perform, how workers can 

identify and avoid hazards, and who workers should contact when safety and health issues or questions arise. The 

program should also include an explanation of the workers’ rights to protection in the workplace. 

When developing a safety and health program, employers should start by performing a general hazard analysis of tasks 

routinely performed by employees. Those findings should be incorporated into the comprehensive program. Employers 

should also use their employees’ expertise throughout the program development process, and eventually during the 

updating process, by seeking employee input. Once the program is developed, employers should ensure that they have 

fully and effectively implemented their safety and health program by routinely performing assessments of tasks and 

immediately addressing any observed unsafe conditions. The program should also be updated when safety concerns 

arise and when new equipment, tasks and chemicals are introduced into the workplace. 

Routine training should be provided to all employees on the program’s topics and procedures, and the training should 

also include hazard recognition and the avoidance of unsafe conditions. All training provided to employees should be 

documented. Training ensures that workers know how to safely perform required job tasks. Trainings should be 

performed by a competent person, which is defined by OSHA as “one who is capable of identifying existing and 

predictable hazards in the surroundings or working conditions which are unsanitary, hazardous, or dangerous to 

employees, and who has authorization to take prompt corrective measures to eliminate them.” Any training needs to 

be provided in the employee’s preferred language. This means the training must be provided in the language(s) and at 

the literacy level(s) of the employees.

The Massachusetts Department of Labor Standards (DLS) offers free consultation services to help small employers 

improve their safety and health programs, identify hazards, and train employees. DLS can be contacted at 508-616-0461. 

More information about DLS can be found on their website at www.mass.gov/dos/consult.

The Massachusetts Department of Industrial Accidents (DIA) has grants available for providing workplace health and 

safety training to employers and employees. Any company covered by the Massachusetts Workers’ Compensation 

Insurance Law is eligible to apply for these grants. 
REPORT#: 19MA058 Page 13

ADDITIONAL RESOURCES

OSHA, Safety and Health Topics: Welding, Cutting, and Brazing. 

OSHA, Hazard Communication: Small Entity Compliance Guide for Employers That Use Hazardous Chemicals. OSHA 

Publication 3695. 

MDPH, Massachusetts FACE investigation report #00MA042, Massachusetts Mechanic Killed When A 55-Gallon Drum 

Exploded. 

University of Iowa, Iowa FACE investigation report 98IA045: Arc welder dies in explosion while using an old barrel as a 

worktable. 

Michigan State University, MIFACE investigation report #10MI032: Sewer Administrator Died When Chop Saw Spark 

Caused a 55-Gallon Drum to Explode. 

Northwest Territories WorkSafe: Hazards of cutting empty drums.

National Fire Protection Association, NFPA 326: Standard for the Safeguarding of Tanks and Containers for Entry, 

Cleaning, or Repair. 

DISCLAIMER

Mention of any company or product does not constitute endorsement by Massachusetts FACE and the National Institute 

for Occupational Safety and Health (NIOSH). In addition, citations to websites external to Massachusetts FACE and 

NIOSH do not constitute Massachusetts FACE and NIOSH endorsement of the sponsoring organizations or their 

programs or products. Furthermore, Massachusetts FACE and NIOSH is not responsible for the content of these 

websites. All web addresses referenced in this document were accessible as of the publication date.

REFERENCES

Weather Underground. Weather History. Massachusetts: TWC Product and Technology LLC. 

OSHA Code of Federal Regulations. 29 CFR 1910 Q. Welding, Cutting and Brazing and H. Hazardous Materials. 

Massachusetts Executive Office of Public Safety and Security, Department of Fire Services. Welding, Cutting & Other Hot 

Works.

Code of Massachusetts Regulations, Board of Fire Prevention: 527 CMR 1 Massachusetts Comprehensive Fire Safety 

Code

OSHA Code of Federal Regulations. 29 CFR 1910.1200. Hazard Communication

OSHA. Recommended Practices for Safety and Health Programs.