Abstract: On April 18, 2005, Employees #1, #2, and #3 were working on a new repackaging line for the pesticide BIDRIN (dicrotophos), which is an organophosphate pesticide. It has an LD-50 of 22 mg/kg, which places it in the highly toxic category, and is rapidly absorbed through the skin. The line operation consisted of equipment that automatically filled one gallon containers of BIDRIN. During the first four weeks of operation, the line had multiple problems including overfilling of bottles, failure of hoses and filling nozzles, tipping over of bottles on the line, puncture of bottles by conveyor equipment, and incomplete installation of caps and seals. These problems led to spillage of the material that required clean-up. Employees #1, #2, and #3 were cleaning up spillage when they were overexposed to the material. All three employees were hospitalized for treatment. According to the employee's accounts, the material contacted their clothing and skin during the clean-up operations. Review of the employee's PPE showed that the employees wore safety glasses, NOMEX coveralls, safety boots with butyl rubber soles that extended 3 to 4 inches up the side of the boot, and nitrile gloves that varied in thickness between 4 mil, 5 mil, and 13 mil. Employees reported that the 4 mil gloves would degrade and tear easily. Dicrotophos does not have an OSHA PEL but does have an ACGIH Biological Exposure Index for Cholinesterase inhibition (depression).