Abstract: On the afternoon of January 20, 1994, an ethylene oxide leak occurred on the p-1 level of Century City Hospital in the Central Services area. This occurred during the sterilization cycle on the ethylene oxide gas sterilizer (AMSCO model #2027). During the cycle, the equipment emitted a pulsing audible buzzer, signifying a mechanical failure. Employee #1 mistook the sterilizer pulsing buzzer for a solid buzzer that signals the completion of the sterilization cycle. When he opened the sterilizer door to transfer the load to a secondary aerator for a second sterilization cycle, ethylene oxide was released into the immediate area, exposing Employee #1 and sending a high alarm reading on the ethylene oxide monitor. A serious accident related citation was issued (5220(j)(3)(c)(3)).