Abstract: On September 11, 2012, Employee #1, a temporary employee of Randstad Horizons d/b/a Placement Pros, was working as a racker-blender at Gibson Wine Company, was exposed to anhydrous ammonia, and died of asphyxia. Employee #1 was found in the west hallway 54 ft from the men's restroom. Upon further investigation, a cellar supervisor was to clear iced juice in Chiller 13 by performing a "hot gas" procedure. The evaporator's temperature is raised by opening a bypass valve that equalizes the refrigerant pressure. The cellar supervisor was distracted in conversation with a graveyard shift supervisor and inadvertently opened the dump valve. The dump valve purges excessive oil from the refrigerant system into a barrel of water. The opening of the dump valve instead of the bypass valve caused oil to discharge and liquid ammonia to release forming a gas cloud. The cellar supervisor evacuated the area but left the dump valve open. The gas cloud engulfed the area and was pushed against the building containing two hallways, a men and women's bathroom, and a break room. The gas cloud formation was captured on a surveillance video, but dissipated within seconds. Approximately one minute before the release, Employee #1 entered the west hallway. It was calculated the refrigerant charge at the facility was 23,640 pounds of anhydrous ammonia.