Abstract: On August 28, 1992, Employee #1 and a coworker were conducting a pasteurizer boilout cleaning process with a product called "PBC-10," which is a solution of 1 percent sodium hydroxide with a balance of water, chelants, and surfactants. Employee #1 added eight quarts of PBC-10 to the compartments on the pasteurizer and then sprayed the outer walls of the pasteurizer with an all purpose cleaner called "Meaner Green," which is a solution of less than 1 percent sodium hydroxide with a balance of water and surfactants. The cleaning process was conducted from outside the pasteurizer. The same cleaning process had been used for the past several years. Employee #1 went on break with his coworker and, during the break, complained of being hot. He went to the nurses' station and complained of burning in his throat and chest. The employee was treated at this station, but then went to the hospital, where he suffered cardiac arrest and died. The medical examiner found no evidence that the death was occupationally related. The cause of death was severe coronary artery disease.