They say bad luck comes in threes. During the summer of 2003, that adage appeared to be true for one chemical plant in Baton Rouge, Louisiana. The plant, which makes refrigerant, inadvertently released three hazardous chemicals in one month. The incidents injured eight people, killed one person and exposed the surrounding community to chlorine gas. Despite the adage, more than bad luck produced this difficult month at the plant; a web of organizational issues contributed to the incidents. Although we do not manufacture refrigerants at NASA, we look to this story this month to learn about findings that are applicable to any pressure system containing hazardous liquids or gases. These incidents remind us that one unforeseen event can cascade into multiple unintended consequences. A key to combating this situation is thorough planning, which looks at process steps in a context of system knowledge. Carefully conducted hazard analyses, training employees for non-routine situations and respect for written operating procedures are all lessons we can learn from these chemical release incidents.