Abstract: At approximately 4:00 a.m on June 6, 1993, an anhydrous ammonia leak affected Employees #1 through #4. These employees were working in the production area processing the mixture to use in baking doughnuts and other bakery products. The pipeline that leaked is right above the production line. Employees #2, #3, and #4 were evacuated by other employees. Employee #1 lost consciousness and was found later by a maintenance employee who was trained for emergency response. All four employees were sent to the hospital, but only Employees #1 and #2 remained hospitalized. Employee #1 suffered serious burns on her skin, irritated eyes, and respiratory problems. Employee #2's symptoms were less acute than those of Employee #1.