Abstract: At approximately 1:15 pm, on June 3, 2010, Employee #1, a cook operator of MCP Foods, Inc. DBA Firmenich, Inc., sustained a serious injury. Employee #1 was working on the orange line in Building 7 and was preparing a cinnamon flavor. At the time of the accident, Employee #1 was cleaning cook pot #6 with water and had filled it with hot water at 80C to 90C. The cook pot is a closed, pressurized system. It is pressurized with nitrogen. The process to clean the cook pot per the SOP (standard operating procedure), the port valve (candy cane, refer to as A) first has the pressure released by opening the valve and leaving it open. Then the lower valve (B) of the drop leg attached to the cook pot is opened to release pressure and left open. Lastly, the upper valve (C) of the drop leg attached to the cook pot is opened to release pressure and left open. These drop legs drain to homogenizers below. This cook pot leads to homogenizer 11 and homogenizer 12 through two drop legs. Therefore, the proper sequence of opening valves is A, B, C. The valves are located on a level below the cook pot at the back of the cook pot. Employee #1 followed the sequence: B, A, C, and said he did so because he thought it was safer this way (less steam was released with less potential for burns). The back of the lid came off and hot water splashed out over the pot and down to the lower level, splashing Employee #1 on the upper back and shoulders. Employee #1 sustained first and second degree burns and was hospitalized for 8 days. Failure to follow procedures and a non-secured lid on the cook pot contributed to the accident.