Abstract: On June 22, 2006, Employee #1 was working as a refinery worker at the Kern Oil & Refinery Company just outside Bakersfield, California. He was attempting to remove a blockage from the South Born Pass crude oil regulator valve. The regulator had previously been isolated from the crude oil stream, and steam at 180 psi had been routed to the regulator body through a steam pipe containing a bleeder valve. Normally, the steam would have exited into another steam pipe with a bleeder valve on the upstream side of the regulator. On the day of the accident, however, the steam failed to pass through and then exit the body of the regulator. Employee #1 found a wire and jammed it into the exit steam pipe, past the bleeder valve and into the blockage. He thought he had closed down the exit bleeder valve to a large degree to prevent a sudden release of hot material. He had not, though. As Employee #1 worked on the blockage with the wire, the blockage released, causing significant quantities of hot steam and crude oil to spray on the ground. Employee #1, adjacent to the release of hot oil and steam and with one knee on the ground, was immediately surrounded by a cloud of steam. He sustained second- and third-degree burns over approximately twenty-two percent of his body. The burns were confined primarily to his legs. He was hospitalized. Causal factors include the failure to have a safe, written procedure for removing crude oil blockages and failure to close down the bleeder valve on the steam exit line before attempting to dislodge the blockage.