Abstract: At 1:30 p.m. on June 19, 2009, Employee #1 was walking through a room where medical testing equipment was manufactured. An autoclave door (5 ft square) blew off, striking a wall approximately 12 ft away. Employee #1 was struck by glass and burned by steam. He was hospitalized at U.C Davis Medical center for lacerations and first-degree chest and face burns. Employee #1 was taking a short-cut through this area at the time of the incident. The autoclave had been under 30 psi pressure, resulting in the equivalent of approximately 72 tons of pressure on the door. After the incident, the employer implemented new maintenance procedures and installed different door hardware.