Abstract: At approximately 2:45 p.m. on January 11, 2000, Employees #1 through #3 were working on a steam line that was connected to a phosphorus storage tank. All insulation had been removed from the steam line and it was very similar in appearance to a phossy water line located nearby. After Employee #1 had cut loose a control valve, he attempted to make another cut in the regular water line, but cut the phossy water line instead. Employee #1 turned the valve with a pipe wrench to what he though was the 'off' position, but instead turned it to full flow. The phossy water sprayed onto his hands, abdomen and legs. He was tied off to the tank and could not break free until Employee #3 finally unhooked his lanyard and got him to the water jump tank. Employee #1 suffered serious chemical burns. Employees #2 and #3 were also exposed to the phosphorus solution, and all three employees were hospitalized. Citations were issued for inadequate personal protective equipment, inadequate training, and inadequate means to notify employees of an imminent hazard.