Abstract: At approximately 9:00 a.m. on September 3, 1992, Employees #1, #2, and #3 were unplugging a bark boiler ash hopper. Employee #3 was stationed at a fire hose. Employee #2 was using a rod to dislodge hot clinkers. Employee #1 was using a potato rake to remove the clinkers. A bridge of ash had formed above the clinkers in the hopper. After the clinkers were removed, the bridge of hot ash dislodged and clouded the area outside the hopper. Employee #1 crawled on his hands and knees through the live ash, which was approximately 10 to 18 in. thick, to an opened window. Employee #3 used the fire hose in an attempt to settle the thick ash. Employee #1 sustained 2nd- and 3rd-degree burns over 75 percent of his body. He died. Employees #2 and #3 sustained minor burns on their feet.