Abstract: At approximately 11:41 a.m. on October 13, 1993, Employees #1 and #2 entered the chlorine room in the sewer department to disconnect empty chlorine tanks and replace them with new ring tanks. Employee #2 used the wrong sequence to disconnect a tank from a manifold, a piece of equipment that automatically releases chlorine into a water system. As a result, the chlorine was released into the air. Employees #1 and #2, along with two other employees, left the area. Employee #1 tried to reenter the area and was exposed to the fumes. Citations were issued for lack of hazard communication training, and having no escape respirators, emergency plan, or labels.