Abstract: Employee #1 died when he fell into a tank containing hot sodium hydroxide. Employee #1 was assigned to lubricate line 401. This involved lubricating the chains, the sprockets, the gears, and the rollers. This did not include lubricating the hoist over the line. For an unknown reason, Employee #1 decided to lubricate the hoist. The normal procedure is to move the hoist to the end of the line where it is not over the tanks. The hoist, however, was not moved to the end of the line. He lubricated the hoist over an open tank of Sodium Hydroxide that was heated to 155-160 degrees. Employee #1 fell into the tank and was immersed with the exception of his head. He died of chemical burns 10 days later.