Abstract: At approximately 1:00 p.m. on August 27, 1992, Employees #1 and #2, two protein conversion plant employees of Foster Poultry Farms, were cleaning in front of a steam cooker. The dump door to the cooker is activated by an air cylinder and toggle device. Once the cylinder has pressed the toggle over center, continuing air pressure is not required to keep the door closed against internal pressure. The procedure for closure requires a visual check for complete closure and confirmation that the toggle device is over center. The door was unsecured and blew open under pressure. Employees #1 and #2 suffered first- and second-degree burns. The steam cooker was carefully examined and cycled 14 times; no mechanical problems with the door or closure device were found. The operator, who was well-trained, was disciplined for not following the explicit procedure for securing the door.