Abstract: Employees #1 and #2 were assigned to unload an autoclave. While Employee #2's back was to the autoclave, Employee #1 opened it while it was still under pressure. A number of safety mechanisms failed, including the locking ram, which prevents the door from being opened: it was incorrectly covered. The microswitch designed to shut the steam off when the ram does not engage malfunctioned. A strainer was missing from the drain line, allowing a bottle stopper to plug the drain. A drain temperature probe that could heat detect actual temperature failed, and the unit remained indefinitely under pressure. Finally, the computer failed to abort the cycle when sterilization levels were not reached within a predetermined time. Employee #1 was pronounced dead at the scene. Employee #2 sustained lower back injuries from being struck in the back by carts in the area.