Abstract: Employee #1, of Packaging Corp. of America, was cleaning a mixing vessel used to make diaper rash ointment. A mixture of pressurized water and detergent is used in a closed system to clean the vessel. When Employee #1 opened the vessel's lid to determine if the level of detergent was at the top of the vessel, water overflowed and splashed over his head, face, and arms. Employee #1 sustained second-degree burns and needed skin grafts on his arms. A causal factor of the accident may have been the overheating of the solution; this is speculative because the temperature strip chart was missing. Another factor may have been that the pumps used to pump the solution may have been left on too long, causing the overflow. An overflow drain pipe on the vessel should have been used as an engineering control.