Abstract: On December 14, 1998, Employee #1, an inventory control specialist in the Shipping and Receiving Department in building CA-1, notified his management that he became ill after inhaling fumes while operating a foam packaging machine, Instapak SPK, Serial Number SP 3914, Sealed Air Corporation, earlier that day. He was evaluated by the site collateral duty first aid team and sent to Washington Clinic, where he was evaluated over again, and diagnosed with shortness of breath due to unclear cause. A follow-up was recommended with a pulmonologist, which was performed at Kaiser Permanente Health Clinic on December 15, 1998 and December 16, 1998. The December 15, 1998 evaluation prescribed avoiding all exposure to polyurethane resin due to reported dyspnea and throat irritation, nausea and vomiting. The December 16, 1998 evaluation provided a return-to-work date for December 20, 1998 with full duties and no restrictions. However, it appeared Employee #1 did not return to work. Employee #1 was admitted to Kaiser Emergency Room on December 23, 1998 and released. Two days later, on December 25, 1998, paramedics were called to the employee's home because of Employee #1's seizures and unconsciousness. Employee #1 was taken to the Eden Medical Center in Castro Valley, California at 1:42 a.m. on December 25, 1998, where he died at 2:02 a.m. The coroner's investigation indicated the cause of death as pulmonary embolism due to membranous glomerulonephropathy caused by chronic viral hepatitis. The medical record was inconclusive whether the occupational exposure was a factor that caused Employee #1's illness and death. Employee #1's employer who was a manufacturer of electronic and computer equipment demonstrated historic air monitoring data provided to the employer by the manufacturer. The historic data indicated values ranging between 0.001 and 0.0045 parts per million. The State of California Division of Occupational Safety and Health's Permissible Exposure Limit, 8 hour-Time weighted average, is 0.005 parts per million. Exposure monitoring was not performed by the employer by the time of Employee #1's last operation of the equipment. However, area monitoring was subsequently performed on January 4, 1999. Employee #1's duties included operation of a foam packaging machine. Solutions A and B were automatically mixed by the machine just before dispensing into bags. Solution A was composed of polymeric isocyanate, 4,4'-diphenylmethane diisocyanate, MDI, Chemical Abstracts Service Number 101-68-8. When mixed, the two components reacted to form foam inside the bags, which were then used in shipment boxes for insulation and protection of electronic equipment. On February 19, 1998, the equipment was installed in building CA-8. On this date, Employee #1 and other inventory control employees received training and instruction on operational procedures and including safety and health information governing operation of the equipment. Employee #1 was originally stationed in building CA-8. The equipment was moved to building CA-1 during the month of June 1998, and Employee #1's duty station was subsequently relocated to CA-1. Employee #1did not regularly operate the machine, but operated it on a fill-in or as-need basis, depending on shipment load and absences of the primary operator. The equipment was operated for 30 to 120 minutes on a daily basis. The size of the room was roughly 30-yd- by-40-yd with a height of roughly 20 ft.