Abstract: On May 6, 2006, Employees #1 and #2 were working for a railroad that served industrial facilities, unloading a shipment of nitric acid in a 50-67% concentration from a railcar into an over-the-road tanker truck. Because their operating procedures were improper, back pressure began to build up in the nitric acid. The equipment used for transferring the acid was unable to withstand the pressure and failed. Nitric acid began to leak at the hose connection, and a mist of nitric acid was released into the air. Ascending the railcar to stop the leak, Employee #1 was sprayed by the nitric acid. Overcome by inhalation of the mist, he fell from the railcar into a puddle of nitric acid. Employee #1 received third-degree burns on his abdomen, hip, lower back, and buttocks. Employee #2 was in the path of the spray as well. He received second-degree chemical burns on his face, neck, and arm. Both employees were hospitalized. Causal factors include a lack of a hazard analysis, failure to identify and implement safe work practices, lack of training, faulty equipment, poor operating design, lack of communication, and failure to provide proper PPE.