Abstract: On April 15, 1998, Employee #29 assigned inmates to clean the Inmate dining room and kitchen area with Lime-Away (Phosphoric Acid). Following breakfast, at 7:10 a.m. on April 16, 1998, Employee #10 assigned inmates to clean the same floor with bleach (Sodium Hypochlorite) diluted in hot water, at 130 degrees Fahrenheit. Gasses were emitted from the mixture of phosphoric acid and sodium hypochlorite and were carried throughout the ventilation system. This resulted in gasses permeating the administrative section of the south facility. Twenty nine employees in the administrative section and adjacent areas were affected by exposure to the gasses. Employee #10 and fifteen other employees were hospitalized. Employee #29 and twelve other employees were exposed but not hospitalized.