Abstract: Employee #1 was supervising the aeration of a load of surgical equipment following treatment in a Biomal ethylene oxide (EtO) gas sterilizer, #0199. He was directed by upper management to remove the load from Vernitron gas aerator #4, model #A3660, Biomal equipment #0198, after it had been through the aeration cycle for only 1 hour. The normal time for the aeration cycle is 8 hours. Employee #1 was exposed to a ethylene oxide, a carcinogen, and experienced headaches, and burning of her right arm, the right side of the face, and her eyes. Employee #1, a supervisor. did not normally remove equipment from the aerator. It was removed early because a doctor wanted to examine a piece of surgical equipment in the load and because it was believed that the surgical equipment was needed for an operation.