Abstract: On May 8, 1989, Employee #1 gave orders to two maintenance workers to replace floor grating in the cupola baghouse while it was in operation. The two refused to go in while it was operation, knowing that it was unsafe. Employee #1 then told Employee #2 to assist him in replacing the floor grating. Employee #2 took the new floor grating up to the bag house and Employee #1 followed him shortly. The maintenance shop steward went in to remove Employee #2 from the cupola baghouse and found Employee #1 kneeling in a fetal position and Employee #2 laying on the back. Employees #1 and #2 were unconscious when found. The maintenance shop steward tried to rescue Employees #1 and #2 but the emission of carbon monoxide from the cupola baghouse was overwhelming so he sought assistance. Once the Employees #1 and #2 were removed, resuscitation provided to them did not succeed. The results of blood tests showed that Employees #1 and #2 succumbed to carbon monoxide poisoning.