Abstract: At about 6:15 p.m. on January 19, 2005, Employee #1, of Rohm and Haas, was mixing chemicals in kettles to make paint. He had started his shift at 6:30 a.m. At approximately 6:15 p.m., his control room operator called him on the radio to mix a solution of caustic beads and water. Employee #1 first added hot and cold water to the mixing tank. He wore a hard hat, safety glasses, and gloves, but he did not put on his acid jacket, which he usually wears when performing this kind of operation. He then climbed the ladder to the mezzanine of the third floor to gain access to the top of the mixing tank. The sodium hydroxide beads that are added to the tank come in a premeasured container with a screw-top lid. Employee #1 knew from training and experience that the caustic beads were to be poured in slowly over five to ten minutes, but, whether due to clumping or human error, the beads were poured in quickly. The caustic beads reacted violently with the water, and the mix shot up the narrow tank through the opening, soaking Employee #1 with the solution mix. There was an emergency eyewash next to the tank on the mezzanine, but no shower. Two showers were on the main third floor, but to get to those, Employee #1 would have had to climb down either a ladder or some stairs. Employee #1 did not want to climb down the ladder for fear of slipping, and his slippery hands could not turn the door knob to access the stairs. He was thus delayed in reaching the shower. He eventually received aid from a coworker, who saw to it that Employee #1 was drenched under the emergency shower and washed his eyes. Employee #1 was treated on the scene and then taken to the hospital. After the accident, Employee #1 was transported to Eden Hospital and then to Doctor's Medical Center, where he was admitted and treated for his injuries. He sustained second and third degree burns to 30 percent of his body, in the form of chemical and thermal burns to his face, arms, stomach, and legs. He stayed in the hospital for approximately two weeks. From the investigation, it appears that Employee #1 added the caustic beads at too great a rate, causing a rapid reaction and increasing the volume of the solution beyond the tank's capacity. He was soaked with the solution, and his injuries were exacerbated by his lack of personal protective equipment and distance from an emergency shower.