Abstract: At 8:00 a.m. on May 29, 1997, Employee #1 began her shift at the labeling machine midway along assembly line #7, which filled and packaged tile cleaner with bleach. After approximately 40 minutes, she became ill from the odor she noticed coming off the line. Employee #1 lost consciousness and fell by her work station. She was revived by coworkers and given oxygen support until emergency personnel arrived. Employee #1 experienced nausea and shortness of breath, and was hyperventilating. She was transported to the hospital, where she was treated and released. She returned to work on June 2, 1997. She had been wearing safety glasses and gloves at the time of the incident. At approximately 1:00 a.m. on June 7, 1997, Employee #2 was working on assembly line #7 to flush out and clean the tank, supply lines, and filler station. The operation had been flushed once, but he thought the tank still contained some residual cleaner, so he began the procedure again. During this second flushing, a section of 2 in. CPVP piping in the ceiling ruptured and contaminated fluid sprayed out and drenched Employee #2. His supervisor was notified. Employee #2 washed off his head and face, changed his wet shirt for a dry, company-supplied smock, and returned to his job while still wearing his wet trousers and shoes. He stated that he began to feel ill, but started to replace the loose hoses inside the filler station. Approximately 45 to 60 minutes later, a coworker discovered him, semiconscious, leaning inside the filler station. He was taken outside and given oxygen support while 911 was called. Employee #2 remembered being short of breath, but said that he could not smell any odors. When the MSP Medi-Vac arrived, they would not transport him because of the heavy bleach smell on his body. The Havre-de-Grace ambulance transported him to the Bayview Burn Center, where he was admitted for observation and released on June 8, 1997. The system was checked and one of the two valves by the tank was found to be closed. Management could not determine who left the valve closed during the flushing process. Two men had been involved in the flushing process; normally this job was the responsibility of one person, and there seemed to be a lack of communication.