Abstract: Employees #1 through #3 were in the vicinity while a crew of seven contract mechanics under the supervision of three refinery workers were using a crane to remove a reactor head from a plugged reactor in a crude alcohol refining unit. A nitrogen purge of approximately 300 psi was being used to maintain an inert atmosphere inside the 41 in. diameter by 40 ft tall reactor. The nitrogen was inadequately vented, and after the bolts on the reactor head had been removed, the pressure built up and blew the head off the reactor as it was being lifted. The 11-ton head fell onto Employee #1, killing him. Distribution trays and catalyst material were blown out of the top of the reactor, striking and injuring Employees #2 and #3. Seven coworkers were also hospitalized after being struck by the flying debris.