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During an inspection by the Occupational Safety and Health Administration (OSHA) of a small coal slag processing plant with 12 current workers, four cases of pneumoconiosis were identified among former workers.The OSHA investigation consisted of industrial hygiene sampling, a review of medical records, and case interviews.Some personal sampling measurements exceeded the OSHA Permissible Exposure Limit (PEL) for total dust exposures of 15 mg/m3, and the measured respirable silica exposure of 0.043 mg/m3, although below OSHA's current PEL for respirable dust containing silica, was above the American Conference of Governmental Industrial Hygienists' Threshold Limit Value (TLV). Chest x-rays for all four workers identified small opacities consistent with pneumoconiosis.This is the first known report of lung disease in workers processing coal slag and raises concerns for workers exposed to coal slag dust. Am. J. Ind. Med. 58:568–576, 2015. © 2015 Wiley Periodicals, Inc.