Abstract: At 9:00 a.m. on August 2, 2020, an employee was cleaning Butter Printers 11 and 12 using a clean-in-place sanitation system. A coworker had connected chemical supply tanks to the incorrect lines causing incompatible chemicals to be introduced into system. When the employee began the cleaning, chemicals were pumped into the mix tank and a chemical reaction occurred releasing chlorine gas exposing him and coworkers in the surrounding areas. Coworkers were evacuated from the area and the employee suffered acute exposure to chlorine gas and was hospitalized to treat acute hypoxemic respiratory failure, chemical pneumonitis, pneumonia, and pleuritic chest pain.