Abstract: Employee #1 was assigned as a spray painter in a paint department. His responsibilities included mixing paints, spray painting piece parts and mobile shelter bottoms, and other non-painting and miscellaneous duties. An epoxy primer was used on all parts to be painted, and a polyurethane paint and hardener was used on the shelter bottoms. Painting was confined to two downdraft spray booths equipped with an electrostatic spray apparatus. Toward the end of the shift, at approximately 5:30 a.m. and after priming and poly painting three shelter bottoms, Employee #1 was found unconscious outside the plant and pronounced dead at 6:40 a.m. at Swain County Hospital in Bryson City, NC. The Office of the Chief Medical Examiner in Chapel Hill, NC, identified the probable cause of death as accidental, an exacerbation of chronic bronchitis and small airway disease, secondary to hexamethylene diisocyanate (HDI) sensitivity and possible volatile respiratory irritants. Employee #1 was potentially exposed to a number of organic volatiles in the primer and poly top coat, including HDI, a component of the polyurethane hardener. Breathing zone air samples representative of Employee #1's exposure to organic volatiles were found to be insignificant with regard to the legal North Carolina occupational health exposure limits. HDI was not detected in the air while the shelter bottoms were spray painted with polyurethane paint. Paint department personnel were provided with and required to wear full body Tyvek suits, rubber gloves, and respiratory protection. Employee #1 was wearing a 3M #7251 half mask negative pressure respirator equipped with a NIOSH-approved organic vapor cartridge and dust/mist pre-filters.