At around 9:15 a.m., a chlorine leak occurred at the end of the cylinder filling cycle in a chlorine conditioning workshop of an industrial gas manufacturing plant. The filling hose had been accidentally ripped off while the cylinder was being handled. The technician had removed the wrong cylinder using his forklift. The personnel evacuated the area, and the installations were made safe. The neutralisation tower was started, and the personnel at the site were confined. At around 9:25 a.m., the operator initiated the plant’s internal contingency plan. The decision was made to inform the residents in the area via the automatic alert system, although difficulties were encountered with the system. A site response team closed the cylinder’s valve and placed suction tubing on the end of the damaged hose. The situation was brought under control and stabilised at 9:35 a.m. At that time, the automatic alert system was switched off. It was estimated that 40 kg had been released.

According to the operator, the accident had been caused by a lack of attention on the part of the technician. He also stated that the forklift’s field of view did not allow a complete view of the cylinder connection.

The following actions were undertaken by the operator to remedy the situation:

• a post was placed in front of each cylinder station with “filling in progress” signage, and the installation of additional automatic safety devices at the station was studied;
• a reminder of safety precautions to be taken when handling cylinders;
• a reminder of the procedure for launching external alert messages via the automatic alert system;
• a group-wide feedback campaign was initiated for packaging sites.