Abstract: At approximately 2:30 p.m. on or about June 24, 1997, a coworker of Employee #1 was filling 100 gram aluminum canisters with ethylene oxide (eto) gas that was being pumped from a scale house to a gas house. The eto gas went into a Grayco pump whose pressure rose from approximately 60 psi to 600 psi, and then to an under-the-cup gasser where the canisters were filled. After taking a break, the coworker went back to the gas house and discovered an alarm warning of a gas leak. An explosion occurred as he was leaving the building. The force of the blast blew off the north door of the gas house, which then struck with the door of the production plant. Both doors flew into the plant, striking and killing Employee #1. Employees #2 through #7 were hospitalized for exposure to chemical fumes. Twenty other workers were sent to the hospital for observation.