Abstract: At approximately 3:30 p.m. on September 20, 1999, Employee #1, a temporary laborer, was assigned to assist another worker feeding flat cardboard sheets into a machine, which then folds and forms the sheets into boxes. He was also to do general housekeeping and cleaning as needed. The machine is located in a large room with one bay door opening to a loading dock. There are fans on the floor and mounted from ceiling rafters, but no air conditioning. Drinking water from a fountain and from portable coolers was provided. Workers take two ten minute breaks at 5:30 and 10:00 p.m. with a half hour lunch break from 7:30 to 8:00 p.m. There is an air conditioned break room upstairs from the production area, but witnesses stated that Employee #1 took his lunch break in his car. At approximately 10:45 p.m. Employee #1 reported to the supervisor's office but was incoherent, disoriented, and confused. He did not respond to directions or reply to inquiries. He was followed by two supervisors out into the parking lot where he attempted to leave. The police were called, and they arrived at the site at 11:15 p.m. Paramedics responded to a call about an employee down and unconscious and attempted to resuscitate him. Employee #1 was admitted to the emergency room with a core body temperature of 108 degrees Fahrenheit and was diagnosed with heat stress and renal failure, and died. The conditions at the time of the accident were generally warm and not too humid. There were some light showers moving into the desert areas. Temperatures at 3:00 p.m. were 98 degrees Fahrenheit with 30 percent relative humidity. At 7:00 p.m. it was 91 degrees Fahrenheit with 39 percent relative humidity. Contributing factors include possible increased susceptibility to heat stress from some prescription medications Employee #1 was taking. Additionally, he was reportedly a heavy individual. This was his first day at the job, and he was unaccustomed to the work pace. Other contributing factors are insufficient training; he was given a general orientation and approximately five to ten minutes of supervision at the task. There was no training by either employer on the hazards of heat stress. Supervisors were not trained to recognize the symptoms of heat stress. Water and Gatorade was available but it is not known whether Employee #1 replenished fluids during the work period. The supervisor did move Employee #1 to two other jobs after the lunch break when his co-worker advised the supervisor that he looked tired. He was advised to take a break, but did not rest in an area where sufficient body cooling could take place.