Abstract: On October 26, 1995, Employee #1 had an asthma attack and went to the San Manuel Medical Center, where she was seen by her personal physician. The doctor released her to return to work on October 27, 1995, without any restrictions. On October 30, Employee #1 finished recording a 21 minute inventory of the railroad cars on tracks on the last hour of her shift (graveyard). She got out of the pickup truck she was driving and was trying to proceed to the depot (dispatcher's office) approximately 20 yards away when she collapsed on the railroad tracks about 10 ft from the truck. At approximately 4:50 a.m., a coworker had spoken to her in person. At about 5:10 a.m., a sub-operator found Employee #1 unconscious on the tracks and immediately ran to call for an ambulance and to notify the shift coordinator that an employee was down. About 5:27 a.m., a safety coordinator arrived and attempted to administer CPR until the fire department arrived. The fire department arrived at approximately 5:35 a.m. and transported her to San Manuel Medical Center. She was then transported by helicopter to Tucson Medical Center, where she died at 11:12 p.m. An autopsy attributed her death to cardiopulmonary arrest secondary to probable asthma (status asthmaticus).