Abstract: On December 31, 1994, Employee #1 was helping transfer gasoline from the Shell Oil distribution center in Los Angeles, CA, to a tanker truck. The Shell facility was a 2 acre area with gasoline storage tanks fed by underground pipe lines from the company's facility in Long Beach, CA. Independent tanker trucks regularly came to the facility to fill their trucks, and then distributed the gasoline to service stations. The transfer requires a coupler with a reduce. The reducer is connected to the truck, which then engages a vapor recovery system. A flexible hose is then attached to the coupler, and a plunger inside is pushed in to allow the transfer of gasoline and engagement of the vapor recovery system. Employee #1 was performing this procedure when he was overcome by gasoline vapors. He was taken to Westlake Community Hospital, where he was diagnosed as suffering from hypoxia and low oxygen levels. It was the employer's opinion that the accident was caused by the coupler being improperly attached and, specifically, that Employee #1 attached the hose to the coupler before attaching the coupler to the tank. Because the lines to the distribution center always have gas vapors in them, connecting the hose to the reducer side of the coupler depresses the plunger and allows vapors to escape into the air. If the coupler is already attached to the truck, however, the gas vapors are taken up by the vapor recovery system and rendered harmless. The coupler that was used by Employee #1 could not be located, and the supervisor was on the other side of the truck while Employee #1 was performing the transfer. There were no witnesses to the accident.