Abstract: On November 27, 2006, Employee #1, a maintenance employee, was troubleshooting an electrical problem in the steam injector room. The employer was producing stainless steel and was using a vacuum oxygenation decarburization (VOD) unit. This unit was recently built and was first used in the summer of 2006. The melt is stirred by bubbling argon gas through the bottom of the vessel. The oxygen gas reacts with the carbon to form carbon monoxide (CO) gas. The CO gas along with other gasses and particulates are removed from the melt by the vacuum system. The exhaust is moved through pipes to a textile filter system. It then moves through the exhaust stack which has a flare to burn off the CO. On the day of the accident, Employee #1 was troubleshooting the electrical system for the textile filters that were not working. The company's internal investigation revealed that the emission control flare burned out in the exhaust stack, causing the CO gas to backup into the steam injector room. Employee #1 was found in the steam injector room unconscious and not breathing. Blood levels taken by the coroner's office from the deceased Employee #1 were sent to the Salt Lake City lab where they confirmed that he was overexposed to carbon monoxide at a level of 447.1 parts-per-million.