Abstract: Sometime between 8:30 a.m. and 2:00 p.m. on July 25, 2012, Employee #1 was working for the Pleasanton Unified School District, in Pleasanton, CA. The Pleasanton Unified School District maintenance department had eight maintenance employees, who serviced all of the schools in the district. The maintenance shop was located in Pleasanton, CA. Employee #1 had been working for the employer for nearly four years. Four months before the incident, a coworker had been assigned the task of securing a lock to a gate at Valley View Elementary School to keep it from swinging. The coworker asked Employee #1 to help the coworker. At the school, Employee #1 and the coworker were to divide the work of grinding and welding. The coworker injured his hand, however, so Employee #1 did much of the welding work. On the day of the incident, he was grinding and welding. He was wearing a welding hood and gloves, but notably he was not wearing a welding jacket or respirator. While Employee #1 was grinding the surface coating in preparation for welding, a piece of hot metal went into his ear, causing a burn and noticeable pain. Employee #1 reported this injury to the employer the same day. (Other reports indicated that the ear injury was due to slag from welding. This was inaccurate, as Employee #1 indicated that his ear injury occurred during grinding.) Employee #1 continued his work after this injury. Employee #1 welded a total of 11 brackets: 4 brackets on the gates near rooms 16 and 17, 4 brackets on the gates between rooms 20 and 22, and three brackets between the multipurpose room and room 26. Employee #1 estimated that he did about 4 hours of welding. Employee #1 was welding angle bracket at various points on the gate, including welds at the bottom of the gate, requiring his head to be close to the welding area. Employee #1 noted that it was a mild day with not much wind. Employee #1 stated that the welding fumes were coming up inside the welding mask. During the welding, he had to remove his welding helmet several times to allow it to air out. Following the exposure to both the welding fumes and the metal burr, Employee #1 experienced fever, headache, and sore throat. The following day, July 26, 2012, he had an appointment for his ear injury. The next day, July 27, 2012, he was taken to an emergency room with a fever, headache, and sore throat. He was hospitalized for four days. On Monday, August 6, 2012, the Cal/OSHA Oakland District office received a call from the Pleasanton Unified School District's human resources analyst about an accident involving an employee "inhaling fumes" and being hospitalized for five days (though elsewhere, the narrative said the hospitalization lasted four days). The opinion of Cal/OSHA's medical unit was that "Employee #1 suffered an episode related to workplace exposures on 7/25/12 during a welding operation on a galvanized gate." As previously mentioned, Employee #1 was welding angle iron onto a galvanized steel gate. Samples of the metals with which he was working were sent to the testing laboratory EMSL for analysis, in part to determine if there were any metals that may have contributed to Employee #1's illness. The angle bracket was 97 percent iron, with trace amounts of other metals. The galvanized steel gate was 98 percent iron, 1 percent manganese, and 1 percent zinc substrate, with a 97 percent zinc coating. The welding wire was composed of iron, copper, and manganese. A complete analysis of the metals was included in the case file. During his investigation, the Cal/OSHA investigator held a meeting with two representatives of the employer. They indicated that the employer was starting to put an injury and illness prevention plan (IIPP) together. The employer could not find that IIPP during the investigator's first site visit. On his second visit, on September 9, 2012, the second representative indicated that the employer still had blanks to complete in the IIPP documentation. An IIPP was provided in respo