Abstract: At approximately 12:00 noon on November 5, 1993, an employee started to clean out the strainer underneath an 800-gallon binder tank. The binder contained 67 percent polyol, 23 percent toluene diisocyanate, 6 percent blue dye, and 4 percent cyclolube. The employee attempted to close the valve that stops the flow of liquid from the tank to the strainer but did not close it all the way. A second employee took over the task and opened the cap to clean out the strainer inside the tank piping system. The binder started leaking out of this opening because of the partially opened valve. A third employee was walking by this area, saw the leak and went to help the second employee. Instead of closing the valve all the way, the third employee accidentally turned the valve in the wrong direction, thereby increasing the flow of the binder. Cleanup procedures were implemented after the incident. At approximately 6:00 p.m., Employee #1, who was working the swing shift, returned from a break and passed by the spill area on the way to the rake room where he usually worked. He started towards the spill in order to turn on a button for the vacuum system inside the rake room. The button is located approximately 13 feet from the binder tank and only 1 foot from the perimeter of the spill. The supervisor, who was still vacuuming the spill with a chemical vacuum, stopped Employee #1 when he was 3 feet from the perimeter of the spill and turned on the button for him. Employee #1 then turned back to go into the rake room. Ten minutes later, he was in respiratory distress and was taken to the hospital, where he stayed for 2 nights and was then released.