Abstract: At about 1:30 p.m. on March 20, 1993, during petroleum refinery start-up operations, Employee #1 was splashed with desalter effluent water that contained crude oil. Employee #1 did not report the incident and worked for the next five days. On the sixth day, he started to spit blood and was hospitalized. At the hospital, he indicated that in addition to being splashed, he had been exposed to smoke clouds and had been suffering headaches, nausea, joint pain, chest pain, and shortness of breath. For the next 24 to 48 hours, he experienced coughing and shortness of breath He also spit blood. No witnesses were found for the smoke incident. Even with treatment, Employee #1's condition deteriorated. He suffered respiratory failure in two weeks and died 29 days after the exposure. The autopsy's final diagnosis is diffuse alveolar damage with extensive pulmonary hemorrhage in both lungs. Investigation could not identify the toxic material the employee inhaled.