Abstract: At approximately 11:00 a.m. on December 6, 1986, Employees #1 through #12, who worked in the final assembly area, were taken to St. John's Mercy Hospital. They were diagnosed with carbon monoxide poisoning, with blood carboxyhemoglobin levels ranging from 21.8 percent to 25.7 percent. First on the scene were St. Louis County Police Department personnel. Then a crew of Coeur Fire Department paramedics arrived and treated Employees #1 through #12 before taking them to the hospital. An official from the St. Louis County Health Department was summoned to check the work area for carbon monoxide. The accident was reported to OSHA at approximately 10:00 a.m. on December 8, 1986. An investigation began the same day at about 1:40 p.m. Workers were not allowed back on the job until December 9. This was when exposure monitoring was conducted, followed by immediate reduction of carbon monoxide levels to below the permissible exposure limit with dilation ventilation.