Abstract: On April 12, 1989, Employee #1 informed management that employees were experiencing headaches and dizziness at their workstations. On April 23, 1989, Employee #1 experienced throat irritation, dizziness and a headache. While driving home at 6:00 p.m., Employee #1 sought medical attention at the emergency room. Employee #1 was examined and disclosed the source of exposure to the attending physician who called Employee #1's employer and asked him to evacuate the building at 7:30 p.m. The building is 30,000 square feet with 36-foot high ceilings at the apex. The building was evacuated and some second-shift employees requested and required medical attention. Employees #2 and #3 were most affected and had the highest exposure after being on the job 3 hours. All affected employees were operating packaging equipment while a propane-powered forklift operated in the area. Carbon monoxide poisoning from the propane-powered forklift was determined to be the source of exposure.