Abstract: At approximately 9:00 a.m. on February 15, 2006, Employee #1 and Employee #2 were unclogging a plugged steam ejector and became unconscious. Apparently, an organo-sulphur compound decomposed, liberating hydrogen sulfide and carbon monoxide when it became exposed to temperatures in the vicinity of 160-degrees Celsius. No local monitoring for hydrogen sulfide, carbon monoxide, oxygen or LEL was performed prior to the start of the maintenance. Employee #1 passed out shortly after the line was broken by the removal of a flange. Employee #2 contacted the Emergency Response Team indicating that it appeared Employee #1 was experiencing a heart attack. Employee #2 began to lift up and move Employee #1, but he, too passed out. Emergency Response Team members arrived. CPR was performed. Both were rushed to the hospital. Employee #2 gradually recovered and was released from the hospital on February 19, 2006. Employee #1 never came out of his coma and died on February 18, 2006.