Abstract: Employee #1, a fill-in forklift operator for Nabisco Brands, Inc., was loading shelves in refrigerator #7 when he struck some refrigerator piping with the raised fork assembly, puncturing an elbow in the ammonia return line. The escaping ammonia contacted his right ear, causing first degree burns. He also suffered inhalatory effects. As he stumbled away from the area of escaping ammonia, Employee #2, returning from lunch, saw him and went to his aid. Employees #2 and #3 also suffered inhalatory effects while helping Employee #1 remove his clothing, which was soaked with ammonia. Employee #4 also suffered inhalatory effects during the evacuation. All employees were taken to the hospital and released in about five hours. Causal factors are: (1) inadequate guarding of exposed ammonia piping; (2) inadequate lighting such as one-half foot candle to 7 foot candles in the store room; and (3) no labeling of pipes.