Abstract: On December 4, 1996, Employees #1 and #2 were consolidating fruit in the refrigerated storage area at a fruit packing facility. It was a large packing house with a year around crew, where fruit was sorted, stored, and packed according to size and quality, and then shipped. At the time of the incident, Employees #1 and #2 were being supervised on an in-and-out basis. Other workers had been using propane-powered forklifts earlier that morning. One of the forklifts, #125, reportedly was not equipped with a catalytic converter and had been emitting nauseous exhaust fumes. Employees #1 and #2 became ill and were diagnosed as suffering from carbon monoxide poisoning by the treating physician. Industrial health care reported the carboxyhemoglobins for both Employees #1 and #2 to be over 32. Direct reading equipment showed elevated levels of carbon monoxide, in excess of 200 ppm, in sheds #1 and #2, which were packing and sorting areas. An effective exhaust ventilation system was available for use in these rooms but was not turned on to conserve energy. Following the incident, one of the forklift units was removed from indoor use. The employer also said it would replace the propane forklifts with electric ones for use indoors whenever possible, and it agreed to keep the ventilation system on in these areas whenever workers were present. The employer was cited for a violation of T8CCR 3203(a)(7), serious, because employees had not been trained about the hazards and signs associated with carbon monoxide exposure; and a violation of T8CCR 5155(e)(1), serious, because the employer should have been aware of the potential for carbon monoxide in areas where propane-powered forklifts were used indoors, and monitored these areas accordingly.