Abstract: At 10:00 a.m. on April 16, 2020, an employee and a coworker entered the Lawn Mixer, a permit-required confined space in the Liquid Department, in order to clean and unjam it. While inside the mixer, the workers cleaned and unjammed a steam pipe which caused it to release steam while both employees were still inside the mixer. The workers had not locked out the mixer from hazardous energy sources, had not conducted atmospheric testing inside the mixer, had not completed a permit form, and did not follow other safety precautions required prior to entering the mixer. The employee was hospitalized to treat second degree burns of both arms, his lower left leg, and left side of his body.