Abstract: At approximately 8:30 p.m. on September 1, 2004, Employee #1, a sanitation maintenance worker for a packing company that processes and packages pork products, was cleaning a Stephan liverwurst processing machine. The procedure for cleaning the processing machine involves a chemical named Envro T004 or trade name Boil Out. The chemical is composed of 80-sodium hydroxide and can create a violent exothermic reaction when it comes into contact with water. As a result, Employee #1 was wearing safety goggles, a safety helmet, rubber gloves, and rubber boots, but was not wearing a water repellant apron that is required by the employer for the work. Employee #1 obtained approximately 5 lbs of the total required 22 lbs of Boil Out in an open bucket to be poured into the emulsifier cooker vat of the liverwurst machine. 25 gallons of water was to be added to the chemical as well. However, the vat already contained hot water at the bottom from the previous rinsing of the machine. As Employee #1 began to pour the Boil Out into the vat, the chemical reacted violently with the water and he was sprayed with the hot water and chemical mixture. This resulted in Employee #1's hands, arms, face, chest, and abdomen to be burned. There were not witnesses to the accident. The accident investigation determined that the incident was caused by the Employee #1 not being properly shielded while mixing a chemical that reacts violently when in contact with water.