Abstract: On October 27, 2009, Employee #1, who had been a permanent employee of a food flavoring manufacture for more than five years and had no other contracts, was performing his duties as a cook operator. Employee #1 was cooking a batch of Natural Lemon ("WONF 858452") in Durarome Reactor #3, in the Redline Cook Department. According to Employee #1, Employee #3, a maintenance mechanic, informed Employee #2 but not him about a lockout/tagout procedure that would take place and affect the cooking done by Employees #1 and #2 at Reactor #3. In addition, the employer did not complete a required lockout/tagout permit. Employee #1 indicated that he was cooking with the drop legs open, so that any pressure build up would be relieved through the drop legs and back to the upstream mixer. However, Employee #3 was working on compressed air lines that powered all reactor steam and vent valves, including those that led to the reactor vent line and would have normally allowed pressure created by the heated sugar to escape safely to an upstream mixer. Employee #1 knew that the initial line pressure of 70 psi to 80 psi had dropped to 1 psi to 20 psi. However, he was at the end of the cooking process, and it was time to add oil to the batch. Employee #1 turned off Reactor #2, including the shear blades and steam, at the switch board. Employee #1 unscrewed the vent pipe, which was shaped like a candy cane and apparently transported pressurized product safely from Reactor #2 to the floor. Employee #1 said that anytime he anticipated pressure build up, he would first open the port valve, but since he had not anticipated pressure, he first loosened the candy cane-shaped vent pipe. Because the valves were closed, the pressure could only be released through the port of Reactor #2. The pressurized product contacted the back of Employee #1's right hand and caused a third degree burn. Employee #1 was hospitalized for more than 24 hours and he underwent two skin graft surgeries. The employer reported the serious incident to the division on November 3, 2009.