Abstract: Employees #1, a vessel operator, Employee #2, an electrician, and Employee #3, a pipefitter, began the day shift by checking the operation of the vulcanizer, a pressure vessel that hardens rubber with steam. The operator on the previous shift had reported that the machine was malfunctioning: it was not achieving the 370 degree F temperature required for the process, and it was filling with water during the initial steam cycle and not curing the rubber. When Employee #1 started the steam cycle, the vessel malfunctioned as described, and the crew decided to abort the cycle. Employee #1 pressed the EMERGENCY STOP button, initiating a circuit that caused the vulcanizer to open 43 seconds later. Employees #1 through #3, who were standing in front of the vessel, were burned by the hot water and steam that was released. Employee #1 died 1 1/2 months after the accident from his burns and ensuing medical complications. Employees #2 and #3 sustained less severe burns; neither was hospitalized. The workers were not aware of the exact timing of the circuitry, and the vulcanizer did not have a safety device to prevent it from opening.