Abstract: On October 10, 2002, Employee #1 entered into a confined space, a manhole, without initiating any lockout or tag out procedures, and attempted to repair a high pressure, high temperature, steam trap line. Employee #1 apparently had tried to remove the trap and was moving within the manhole and apparently struck an internally deteriorated blow down line, causing it to separate from the steam line and releasing 700 to 800 degree Fahrenheit, 250 p.s.i. steam into the confined space. This resulted in blowing Employee #1 out of the manhole, and his receiving third degree full thickness burns over 95 percent of his body. Employee #1 died approximately 10 hours later at the hospital.