Abstract: At approximately 6:00 a.m. on the morning of September 21, 1994, Employees #1 through #10 in the ham and bacon pack areas were complaining of odors and irritated eyes. Before their shift, the cleanup crew used a chlorine solution for sanitation and may not have diluted or rinsed the solution thoroughly. At 6:05 a.m., an ammonia line in the bacon brine chill room broke because a hanger gave way. The ham and bacon pack rooms are separated from the bacon brine chill room by a few rooms that were closed off and therefore limited the employees' exposure to ammonia, although the emergency response crew took readings to ensure employee protection. Employees #1 through #10 became very concerned as the day went on about the exposure to both ammonia and chlorine. Eventually Employees #2, #5, #7, #8, and #9 were hospitalized.