Abstract: On April 12, 1988, the drycleaners in a plant that manufactures hi-tech sweaters from synthetic and cotton yarns were used for the first time with perchloroethylene. The cotton sweaters are water washed and the synthetic sweaters are drycleaned; the Donini washing/drycleaning machines are single units with both capabilities. Although the plant had been in operation since January 1988, and the washing/drycleaning machines had been in place since February 1988, the actual drycleaning operation was not run until April 11, 1988. On April 12, 1988, a Donini technician was on site to insure proper functioning of the machines. Some of the employees noticed a strong odor from the drycleaners and some experienced headaches. On April 13, the employees noticed the same odor and symptoms. One employee fainted due to a heart condition. On April 14, the drycleaners were started at 7:30 a.m. By 7:45 a.m. the odor was very strong in various parts of the finishing room. At 8:15 a.m., the doors in the room were opened, which helped control the odor. At 10:00 a.m., numerous employees started experiencing nausea, headaches, vomiting, breathing problems, fainting, muscle weakness, and eye and throat irritation. At approximately 1:00 p.m., the plant was evacuated due to employees experiencing fainting and severe reactions. Employee #3 was vomiting blood and was transported to the hospital. EMTs transported 40 to 50 employees to the hospital. Employees #1 through #27 were hospitalized and treated for inhalation of perchloroethylene. Employee #10 was placed in intensive care due to a pre-existing condition. The Donini units have their own solvents recovery unit with charcoal absorbent; are exhausted through a recovery system; and have numeric controls. The machines are located in a 54,289 square ft room with 14 ft ceilings. This same room contains sewing operations, steaming, inspection, and packaging; 75 employees work on each shift. There are three HVAC units in the room, all with return air vents on the same side of the room as the drycleaning units. No fresh air is brought in; all air is 100 percent recycled through the HVAC systems. The incident was caused by poor design of the finishing room; placement of the HVAC; and lack of makeup air. The building is less than one year old and is very tight. The employer plans to separate the drycleaning area from the finishing room and place it on a separate ventilation system, which should alleviate the problem.