A worker was assigned to perform maintenance on a vacuum valve using a company procedure that differed from the one recommended by the valve’s manufacturer. The worker, who’d been at the company for only six months, was alone. During this process, a threaded rod released from an internal nut and, under pressure, was driven through the worker’s head. He was found by a co-worker and died two days later. The worker had worked on only one of these valves before this incident. The company didn’t provide formal training on such valves and the supervisor had assumed that the worker had gotten training on the hazards associated with the company’s procedure for disassembling such valves, with no basis for that assumption. The company pleaded guilty to failing to provide information, instruction and supervision to a worker and was fined $125,000. The supervisor pleaded guilty to failing to ensure that the worker was sufficiently trained and/or supervised to perform the task safely and was fined $5,000 [Professional Valve Service Ltd. and Joe Heynsbergen, Govt. News Release, Jan. 6, 2016].