Abstract: At approximately 4:00 a.m. on July 2, 1992, Employee #1 and a coworker were charging hydrogen cyanide from two 166-pound cylinders into a hydrogen cyanide holding tank. They were wearing chemical splash protective equipment including rubber boots, gloves, hoods, and airline respirators. From an adjacent area, the coworker acted as the observer while Employee #1 disconnected the dry disconnects on the nitrogen line and hydrogen cyanide line. The system operated under 70 psig. Hydrogen cyanide sprayed onto Employee #1. He went under the emergency eyewash and shower for approximately one minute or less, according to the coworker. He was given hydrogen cyanide antidote first aid on site. Employee #1 died. Hydrogen cyanide sensors in the hydrogen cyanide cell and in the observation room indicated a maximum reading of 50 ppm. Alarms and emergency ventilation were activated.