CASE-STUDY OF FACTORS CONTRIBUTING TO A CRISIS BUILDING

Employees of a communications firm experienced an acute outbreak of no nspecific illness related to the workplace. Symptoms consisted primari ly of coughing, throat irritation, shortness of breath and disorientat ion. Fifty-one individuals sought emergency medical care, and the buil ding was evacuated. A multidisciplinary team was assembled to investig ate and resolve the problem. Investigation activities focused on three major areas: epidemiology; environmental measurement; and mechanical engineering. Results indicated that the outbreak was due to multiple f actors working in concert. The inside of the air handling system was c ontaminated with microbial growth and particulate matter; chemical pro ducts were used throughout the building with little control over use p atterns; and the HVAC system was not delivering acceptable quantities of outdoor air to the employees' breathing zones. Two unusual events m ay have triggered the employees' response. An unusual odor/taste was r eported, and the outside air damper abruptly opened and closed, possib ly dislodging particulate matter from inside the air handling system. It appeared that psychosocial factors played an important role. Preven tion of similar crises could be achieved by implementation of a policy /procedure that addresses specific responsibilities, communications, p reventive maintenance, acceptable outdoor air ventilation rates, and g uidelines for reporting and investigation.