Abstract: On July 18, 2006, Employee #1 and a coworker were working for a plumbing, heating, and air conditioning contractor at a jobsite in West Sacramento, CA. They were on top of some elevated steel pipes, tightening cap screws on a butterfly valve. As they worked, Employee #1 and his coworker were not aware of something unusual about the pipes. On March 29, 2006, their employer had shipped two pieces of condenser steel piping 30 feet long from its fabrication shop to the jobsite. Each piece of pipe had an elbow with a cap on one end and a valve with a gauge on the other end coming out of another cap. When the employer shipped these pipes, they were pressurized to about 90 to 95 psi. They were shipped on a lowboy tractor trailer on the highway to the jobsite, unloaded via a crane, and placed in the location they were in at the time of the accident. The employer had pressurized these pipes, but it did not inform the crane operator or the general contractor that the pipes were pressurized during shipping or installation. The pipes were installed in the ground, and until July 18, 2006, construction went on around and on top of the pipes, which were still pressurized. During this time period of 112 days, the employer conducted training at and inspections of the job site. It did not at any time inform or train employees that these pipes were pressurized. Further, the pipes were not labeled or marked to indicate their pressurization. Inspection records revealed that other pipes at the site had been pressured for testing purposes but only for short periods of time up to 24 hours. On the day of the accident, Employee #1 got off the pipe to measure the lengths that other pipes would have to be to connect to the two 10-inch lines coming out of the ground. He was standing on the ground loosening the bolts to the caps on a pipe. Because of the pressure, the cap flew off and struck Employee #1 in the head, causing a fracture. Employee #1 died at the scene from the trauma. The employer was cited for the following violations of CCR, T8:1-1, SERIOUS, 1511(a): No worker shall be required or knowingly permitted to work in an unsafe place, unless for the purpose of making it safe and then only after proper precautions have been taken to protect the employee while doing such work. 2-1AR, SERIOUS, 3329 (d): When dismantling or opening closed pressurized or gravity fed systems, internal pressure shall be relieved or other methods utilized to prevent sudden release of pressure or spraying of liquid.