Abstract: THIS EVENT OCCURRED AT A SOFT DRINK BOTTLING PLANT. EMPLOYEE #1 WAS IN THE PROCESS OF DISCONNECTING A COMPRESSED GAS CYLINDER CONTAINING CHLORINE FROM A MODEL #91-100 WALLACE AND TIERNAN GAS CHLORINATION UNIT. THE EMPLOYEE THOUGHT THAT HE HAD TURNED THE TOP VALVE HANDLE ON THE SUPPOSEDLY EMPTY COMPRESSED GAS CYLINDER TO THE CLOSED POSITION, BUT CHLORINE GAS CAME HISSING OUT OF THE CYLINDER WHEN HE DISCONNECTED THE AUTOMATIC CHANGE-OVER UNIT FROM THE CYLINDER. EMPLOYEE #3 HAPPENED TO BE WORKING ON A LADDER NEAR THE CHLORINE ROOM WHEN THE LEAK OCCURRED. EMPLOYEE #2 APPROACHED THE CHLORINE ROOM IN ORDER TO EVALUATE AND ASSESS THE SITUATION. THE INJURED EMPLOYEES EXPERIENCED BURNING, TEARING EYES AND BURNING, IRRITATED RESPIRATORY TRACTS, ALONG WITH COUGHING AND DIFFICULTY TAKING DEEP BREATHS. CONTRIBUTING FACTORS INCLUDED: A CYLINDER VALVE THAT WAS DIFFICULT TO COMPLETELY CLOSE; A MALFUNCTIONING "EMPTY" INDICATOR; A LACK OF SCALES AND A LACK OF LEAK CHECKS.