Abstract: While attempting to pull metal cabinets, which had fallen from a conveyor system, out of a tank containing a heated sodium hydroxide solution, Employee #1 apparently slipped and fell into the tank and was submerged in the liquid at a depth of approximately 4 ft. Sustaining chemical burns, Employee #1 was hospitalized from July 10, 1991, until he died on December 23, 1991. Employee #1 was not using a safety belt and lanyard or following the procedure to remove cabinets. The employer determined that the accident could have been prevented and instituted a procedure whereby non-routine tasks involving the stripper tank would not be performed without supervisor notification, and a safety belt and tether line would be required.