UNITED STATES
DEPARTMENT OF LABOR

On May 18, 1992, Employees #1 through #12 were working the second shift on a cook line making ready-to-eat chicken fried steaks. Employee #7 was preparing the meat, while the rest of the employees inspected and packaged it. At about 3:30 p.m., one of the employees complained of a severe headache and left work. At about 5:30 p.m., Employee #3 complained of a light headache and fainted. She left work and the problem was attributed to an existing medical condition. As the shift progressed, other employees on the line complained of headaches and nausea. The safety manager was summoned at around 7:00 p.m. Sampling was conducted for carbon dioxide and ammonia hydroxide, with negative results. The fire department was called for assistance and arrived around 8:15 p.m. Carbon monoxide was detected during further sampling, but was dismissed as a problem. At 9:00 p.m. Employees #2 and #5 were observed weaving and were taken off the line. The line, including the deep fry cooker, was shut down. Three employees were transported to a hospital via ambulance. The rest made their own way to the same hospital. At the hospital, tests indicated that Employees #1 through #12 had elevated carbon monoxide levels in their blood as of 11:00 p.m. They were treated for carbon monoxide overexposure. Subsequently, the only apparent source of carbon monoxide, the cooker, was restarted; sampling indicated elevated levels of carbon monoxide around the cooker burners. These levels were attributed to maladjusted burners and a defective exhaust fan.