Abstract: On June 27, 1990, most of the first shift employees were inventorying the plant. Two propane-powered forklifts were being used to move parts from one end of the plant to the other to be weight-counted. The two spray booths in the plant were the only source of exhaust ventilation. They were shut off at 1:00 p.m. By this time, most of the employees had headaches. Symptoms including headaches, dizziness, and nausea became apparent between 3:00 p.m. and 4:00 p.m. The plant was evacuated at approximately 4:30 p.m. Employees #1 through #15 went or were taken to hospitals. No employees were admitted. Carboxyhemoglobin levels were 17.2 percent to 19.6 percent. Back calculation of exposure levels was 209 ppm to 257 ppm as 8 hours time weighted averages in air.