Abstract: As part of his regularly assigned duties, Employee #1 was operating a retort vessel as it neared the end of a venting cycle. The vessel was not at full operating pressure. Employee #1 was adjusting the door tightness and was standing next to the door when the door latch mechanism failed. The built-up internal steam pressure blew the door open. Employee #1 was struck by the door and was also burned by escaping steam. He suffered first- and second-degree burns over 70 percent of his body, internal injuries, and a broken leg. Employee #1 died. A defective screw in the latch mechanism, which had been in place for approximately 10 years, was a causal factor in the accident.