Abstract: On the afternoon of November 15, 1995, Employee #1, a ferrous foundry worker, was at his duty station operating a conveyor belt that carried raw materials such as coke, limestone, etc., from rail cars to the storage bins in the upper levels of a melting building. His duty station was next to the bins in an area of the foundry above the cupolas, and was adjacent to the afterburner (a component of the cupola emission system). There was a sudden release of carbon monoxide from the cupola system. Employee #1's body was discovered later that evening on a set of outside stairs leading from his duty station to the conveyor belt. He was pronounced dead at the scene. There were no carbon monoxide monitors or alarms in the foundry; Employee #1 did not have respiratory protective equipment that was adequate for protection from exposures to carbon monoxide; and he had not been informed that carbon monoxide was a hazard in his area of the foundry. The official cause of death listed by the coroner was "acute asphyxiation due to carbon monoxide poisoning."