Abstract: Employee #1, a production worker for California Portland Cement, was in the heater-cure clinker area of the cement production section. He had been trained to wear an asbestos suit and hood when releasing hot gasses from the kiln during the process known as tertiary air duct drop out. Employee #1 dropped his hard hat and, while retrieving it, inadvertently placed his head into the stream of hot gasses. He suffered second- and third-degree burns to the top of his head and was hospitalized. Some skin grafting was required. Employee #1 had bypassed training and written procedures by not wearing his helmet and face shield.