Abstract: On October 16, 2002, Employee #1, a journeyman stationary engineer, employed by SUNY-Buffalo was bringing heat up in Crosby Hall on the South Campus when a high-pressure steam line ruptured. Employee #1 burned 100-percent of his body from scalding steam and was pronounced "dead at the scene." An autopsy report listed the cause of death as "asphyxia due to steam burn." Although the exact cause of the rupture has not officially been determined, it appears that a condensation induced water hammer was the probable cause. Water hammer is the unexpected release and associated shock wave of high pressure steam/condensate. The contributing factors to this event were: 1) condensate in the high pressure portion of the line; 2) reverse slope of high pressure steam line and condensate return line; 3) age and condition of steam line components; 4) use of cast iron in a high pressure steam system; 5) inadequate or inoperative steam traps; 6) a change from normal start-up procedures; 7) inadequate training in the control of hazardous energy; and 8) lack of established/documented procedures to assure that all hazards have been identified and minimized.