Abstract: AT APPROXIMATELY 7:20 PM ON AUGUST 29, 1984, EMPLOYEE# 1 STARTED TO PURGE THE OIL FROM AN AMMONIA GAS REFRIGERATION SYSTEM AT A SOFT DRINK BOTTLING PLANT. IT WAS THE FIRST TIME HE HAD ATTEMPTED THIS PROCEDURE AND HE HAD NOT BEEN PROPERLY TRAINED. HIS PURGING TECHNIQUE WAS FAULTY, CAUSING HIM TO ACCIDENTALLY RELEASE A LARGE AMOUNT OF ANHYDROUS AMMONIA INTO HIS BREATHING ZONE. HE WAS MOMENTARILY BLINDED AND UNABLE TO LOCATE THE VALVE TO TURN OFF THE AMMONIA, WHICH WAS NOW BEING RELEASED AT GREAT SPEED FROM THE REFRIGERATION SYSTEM. WITH HIS EYES, SKIN, AND THROAT STINGING HE WAS FORCED TO ABANDON THE ATTEMPT. HE CRAWLED OUT OF THE ROOM. SUBSEQUENT ATTEMPTS BY EMPLOYEES ONE THROUGH EIGHT TO RE-ENTER THE ROOM (WITH DEFECTIVE AMMONIA GAS MASKS) ALSO FAILED. SUPERVISORS THEN ACTIVATED THE EVACUATION PLAN. BEFORE EVACUATION BEGAN, AND DURING EVACUATION, MANY OTHER EMPLOYEES WERE EXPOSED TO THE AMMONIA GAS, WHICH HAD DIFFUSED THOUGHOUT THE PLANT. EVENTUALLY MUNICIPAL FIREFIGHTERS WITH SCBA'S TURNED OFF THE VALVE. APPROXIMATELY 300 TO 400 POUNDS OF AMMONIA ESCAPED. TWO EMPLOYEES OF MID-ATLANTIC CANNERS ASSOCIATION, THREE MUNICIPAL FIREFIGHTERS AND ONE TRUCK DRIVER WHO HAPPENED TO BE IN THE PLANT WERE HOSPITALIZED OVERNIGHT AND RELEASED THE NEXT MORNING. THE OTHER EMPLOYEES WHO WERE SOMEWHAT AFFECTED BY THE AMMONIA EXPOSURE WERE EXAMINED AND RELEASED THE NIGHT OF THE ACCIDENT. THERE APPEAR TO BE NO EFFECTS OF THE EXPOSURE TO ANY OF THE EXPOSED EMPLOYEES.