Abstract: Employee #1, a maintenance electrician for a company that manufactures beverage- dispensing equipment, was on the roof of a building, checking a compressor that was installed a few days previously, but was not functioning properly. He was visually examining the compressor when its line burst and R-22 refrigerant sprayed out onto his face, neck, and left hand. Employee #1 sustained first- and second-degree burns, for which he was treated and released from Glendale Memorial Hospital. He was subsequently admitted to Torrance Memorial Hospital when the burns became infected. While he was being treated for the infection, Employee #1 died from a pre-existing heart and respiratory condition.