Abstract: On January 31, 1995, Employee #1 was checking a process boiler that had been shut down the previous day. He had been instructed to determine whether the boiler's pressure and temperature were low enough to proceed with opening of the top inspection hatch. Employee #1 proceeded to the top of the boiler, completely released the strong back bolts, and pried open the inspection hatch. He apparently made no attempt to relieve the boiler's residual pressure, or to make sure that the water level was below the hatch, as per written procedure. He sustained serious scalding injuries to his face, arms, back, and legs, and was hospitalized until February 17, 1995. .