Abstract: On November 3, 2005, Employee #1 and two coworkers were using a pool cleaning product to clean and scrape a lap pool at the Sage Springs Spa at the Destination Sunriver Resort, Inc. Employee #1 was the supervisor of his two coworkers. The product they were using, Red Devil TSP-90, was not removing the residue, so Employee #1 decided to add another product, which was labeled "chlorine granules." It reacted by foaming. Employee #1 told his coworkers to "get out of here and open the windows as you go." Employee #1 came out of the building a couple minutes later. He was visibly pale and coughing continuously. The general manager of the site suggested that emergency medical services be called, but Employee #1 declined and went home. He later went to the hospital, where he was initially kept overnight for observation. He remained at the hospital another night for treatment.