Abstract: On September 29, 2002, Employee #1, who worked for a manufacturer of ice cream and associated products, was engaged in the kosherization of the mocha mix vat, a process that performed every other week. This process entails the sterilization of three vats by filling them with 1,600 gallons of water heated to 209 degrees F. Employee #1 had pumped 500 gallons out of one of the vats and was attempting to close the valve of the gravity-fed water pipeline by hitting it with a rubber mallet, which was standard operating procedures because the valve tended to stick due to heat expansion caused by the hot water. As Employee #1 struck the unit, the 23-lb valve popped out of its seating and sprayed him with hot water in the region between his waist and knees. The valve reseated itself ceased spraying. Employee #1 was hospitalized and treated for second- and third-degree burns on the front of his thighs. Employee #1 was working without supervision at the time of the accident. During the accident investigation it was revealed that the valve was not properly maintained and was not anchored by a retaining plate, which had been supplied, along with its nut, with the vat and valve when they were acquired by the company thirteen years earlier. The company rewrote its procedures to require that every vat and valve be equipped with a retaining plate and nut.