Abstract: ON FEBRUARY 5, 1988 A PLATING TANK CONTAINING ABOUT 800 GALLONS OF SODIUM CYANIDE SOLUTION WAS BEING DRAINED SO THAT THE ANODE BARS COULD BE CLEANED AND THE TANK REFILLED WITH A ZINC PLATING SOLUTION. AFTER BEING EMPTIED, THE TANK WAS REFILLED WITH WATER TO DILUTE THE REMAINING SODIUM CYANIDE AND SLUDGE. ON FEBRUARY 6 THE CLEANING OPERATION WAS CONTINUED AND THE TANK AGAIN DRAINED. THE TANK CONTAINED APPROXIMATELY 4 TO 6 INCHES OF WATER AND "SLUDGE." EMPLOYEE #1, A PLATER, WAS ASSIGNED TO CLEAN THE ANODE BARS. HE SUPPOSEDLY USED A SOLUTION OF WATER AND SODIUM HYDROXIDE FOR CLEANING, BUT ANOTHER EMPLOYEE STATED THAT EMPLOYEE #1 HAD ACTUALLY OBTAINED SOME HYDROCHLORIC ACID FROM A COMPLETELY UNLABELED TANK. EMPLOYEE #1 WAS FOUND LYING, UNCONSCIOUS, ON THE BOTTOM OF THE TANK. UPON ARRIVING AT THE HOSPITAL, HE WAS FOUND TO HAVE A BLOOD CYANIDE LEVEL OF 1.6 MG/L. EMPLOYEE #1 WAS ESSENTIALLY "BRAIN DEAD." LIFE SUPPORT WAS DISCONTINUED ON FEBRUARY 9, 1988. NO AMYL NITRATE WAS AVAILABLE AT THE PLANT FOR EMERGENCY TREATMENT. THERE WAS NO HAZARD COMMUNICATION TRAINING, NO TANK LABELING, NO PROCEDURES FOR CONDUCTING CLEANING OPERATIONS, INADEQUATE PERSONAL PROTECTIVE EQUIPMENT, ETC.