Abstract: At approximately 10 p.m. on July 31, 2000, Employee #1, the night supervisor, was observing the progress of a steam cleaning operation involving the out-of-service vapor recovery line to tank #1025. He was investigating the area around the 10 in. blind flange and the spreader bars, which was reportedly plugged, when a stream of water began to flow from the top of the flange. Employee #1 began to smell hydrogen sulfide gas and saw a stream of water and light hydrocarbons start to gush out of the area around the spreader bars and cover the 6 ft square scaffold platform. He later stated that he held his breath, climbed over the railing and began to descend the 21 ft scaffold ladder. Shortly thereafter, his hands and feet slipped from the rungs and he fell to the asphalt floor. Employee #1 suffered a fractured right femur, right knee, and left shoulder, and was hospitalized for 10 days at Long Beach Memorial Hospitalized. Among the causal factors that led to the accident were the lack of controls to safely dispose of the oil-water mixtures and the foreseeable toxic effects of hydrogen sulfide during maintenance activities. There were no bleed valves on the system to relieve pressure in the piping and no covers/diverters over the flanges to direct oily-water down instead of onto the ladder rungs.