Abstract: On July 11, 2008, Employee #1, the lead operator of a sewage treatment plant, noticed that the residual levels had dropped in the tanks, and he decided to add more ammonium hydroxide to increase the residual levels. Employee #1 removed the camlock fitting and line from an empty 335 gallon tote and installed it to a full 335 gallon tote containing ammonium hydroxide solution. While installing the camlock fitting and line onto the full tote, he failed to secure the camlock fitting latches into the valve coupling grooves. As Employee #1 turned the valve to the open position, the camlock fitting and line sprung off the coupling and sprayed ammonium hydroxide onto his upper legs and groin area. Employee #1 immediately turned off the valve and secured the camlock fitting latches into the coupling grooves. He then went to the emergency eyewash/shower, approximately 120 feet away, to rinse off the ammonium hydroxide. Employee #1 rinsed for approximately 15 minutes, but did not take off his clothing. He then drove a golf cart to the administrative building, to notify management of the accident. Management summoned emergency medical services at approximately 9:45 a.m. and rinsed Employee #1 with an emergency eyewash/shower, located in the administrative building, until the ambulance arrived. Employee #1 was transferred to the hospital via ambulance at approximately 10:00 a.m. He was hospitalized for two days for treatment of chemical burns to his upper legs and groin areas. The use of ammonium hydroxide to control residual levels in tanks was a new process at the facility. No written procedures or hazard assessments were completed for the assigned task. Employee #1 was wearing safety glasses but no other form of PPE during the accident. Employee #1 said he was in a hurry and normally would have worn rubber gloves and a respirator while transferring the camlock and line from one tote to another.