Abstract: On February 17, 1987, a fire and explosion occurred at a process machine where viscose casings are manufactured. A buildup of carbon disulfide occurred at tank #3 of process machine #9 and the vapors were probably ignited by a heat exchanger at that tank. The fire was sucked into the ventilation system and spread to other parts of the process area. Employees #1 through #6 were all in the process area. Employee #1 was at the wet end of machines #1 and #2, and suffered from smoke inhalation. Employee #2 was at the extrusion end between machines #9 and #10, and sustained second-degree burns on his hands and arms. Employee #3 was at tank #7 between machines #9 and #10, and suffered burns on his back. Employee #4 was at the extrusion end of machine #5, and was injured by foreign objects in his eyes. Employee #5 was at the dry end between machines #8 and #9, and complained of throat irritation. Employee #6 was by the old "B" tanks of machine #9, and suffered from smoke inhalation. Employees #1, #2, and #6 were hospitalized. A semi-continuous monitoring system was being installed to detect carbon disulfide, hydrogen sulfide, and ammonia, but it was not yet operational. There were gaps in the insulation on the heat exchanger and the surface temperature of the exchanger was just slightly below 140 degrees Fahrenheit.