Abstract: EMPLOYEE #1 WAS ATTEMPING TO REPAIR A LEAK IN A REFRIGERATION SYSTEM. ALTHOUGH WRITTEN AND ESTABLISHED PROCEEDURES REQUIRED IT, THE EMPLOYEE DID NOT DRAIN AND PURGE THE PRESSURING SYSTEM BEFORE BEGINNING THE REPAIRS. HE HAD BEEN THE SHOP FOREMAN FOR 2 1/2 YEARS, AND HAD RUN HIS OWN BUSINESS FOR 22 YEARS BEFORE THAT. HE BEGAN HEATING A COPPER TUBING JOINT THAT WAS HELD TOGETHER WITH ZEBAN SOLDER. THE HOLE ENLARGED, CAUSING THE FREON TO SPRAY OUT INTO THE TORCH FLAME. THE PHOSGENE THUS CREATED SPILLED INTO THE EMPLOYEE'S BREATHING ZONE, CAUSING RESPIRATORY DISTRESS AND SUBSEQUENT HOSPITALIZATION.