Abstract: At approximately 10:30 p.m. on September 27, 2002, Employee #1, an irrigation laborer, was driving a company-owned 1991 Ford Explorer, California tag # 3XGS858, at his place of employment. The next morning at approximately 6:00 a.m. on September 28, 2002, coworkers of Employee #1 reported to the shop for work and realized Employee #1 was missing. The irrigation Lead Man went to where Employee #1 was last seen and found him dead in the driver's seat of the Ford truck. The engine was running and the doors and windows were closed. The coroner's report stated the cause of death as carbon monoxide poisoning; Employee #1's carboxyhemoglobin was measured at 54.7 ppm. Subsequent air monitoring inside the vehicle with the engine running did not detect carbon monoxide during the first eleven minutes of monitoring when the heater and fan controls were turned off. But, when the vehicle's air conditioning was turned on, and the heater fan and temperature controls were at the highest setting, the carbon monoxide concentration exceeded 999 ppm (range 178 ppm to 999 ppm) within 47 minutes. During a detailed accident investigation it was revealed that earlier in the day on September 27, 2002, it had been reported to the shop's Acting Supervisor that the vehicle's tailpipe was dangling. The Acting Supervisor did not remove the vehicle from service, even though the hanging tailpipe would have compromised the exhaust system and made discharge of carbon monoxide problematical. Additionally, a couple months prior the accident, the Ford Explorer had been in for service due to engine performance problems. As part of the service, the vehicle's catalytic converter was removed along with its packing material. This meant that the converter no longer functioned to remove toxic exhaust gases, such as carbon monoxide, nitrous oxide, and hydrocarbons. The converter was then reinstalled and the vehicle was returned to service. The employer was cited for a violation of T8CCR 3203(a), because its IIPP did not identify the person with the responsibility and authority for the program, and for failure to implement the written IIPP by allowing the Ford Explorer to be returned to service with a defective catalytic converter and to remain in service with a dangling tailpipe. The employer was also cited for a serious, accident-related violation of T8CCR 3328(c), for allowing a piece of equipment with defective parts that created a hazard to be used, and for a serious, accident-related violation of T8CCR 5155(c)(1)(a), for allowing an employee to be exposed to carbon monoxide above the PEL and STEL.