Abstract: At approximately 11:30 a.m. on February 16, 1999, Employee # 1 was trying to complete the first cycle of a procedure to combine two chemicals under pressure to create a new solvent. He had made three attempts to draw small amounts of the chemicals into a chamber and was on his fourth attempt when it exploded. He was struck by shrapnel from the ruptured tubing, which imbedded in his face and arm. His hearing was also damaged by the noise and pressure of the explosion. Employee #1 was helped by a coworker from out of his area, who applied emergency eye/face wash and got him into the deluge shower. The Sacramento County Fire Department undertook decontamination procedures before he was transported to the hospital. Surgery was performed in both the emergency room and in the operating room to remove the shrapnel, but Employee #1 continued to have hearing problems from the explosion. His equipment was not put back into use by his employer because of questions about its design and the use of isolation cells and chemical detonability.