At approximately 8:20 p.m., a malfunction in the ammonia refrigeration system caused overpressure in the Heat Exchanger 5 Surge Drum, triggering the release of approximately 275 pounds of anhydrous ammonia. The discharge occurred in a two-phase flow, producing a dense toxic cloud that quickly settled at ground level, exposing employees and nearby personnel to concentrations classified as “Immediately Dangerous to Life or Health (IDLH).”
“At the time of the release, 286 employees and contractors were onsite,” the report stated. Emergency responders found over ten individuals unconscious. In total, 33 people were transported to hospitals, with four admitted for serious injuries, including one to intensive care. The facility’s ammonia detection system failed to trigger alarms, no evacuation signal was sounded, and no emergency shutdown was initiated, allowing the situation to escalate.
The CSB identified significant deficiencies in Cuisine Solutions’ Emergency Action Plan. The plan did not differentiate between indoor and outdoor releases, lacked procedures based on wind direction, and provided no guidance for shelter-in-place decisions. Employee training and emergency drills were insufficient, delaying evacuation and increasing exposure.
Property damage was estimated at $3 million, including production losses, with parts of the plant remaining offline for up to 38 days. The incident highlighted both mechanical failures and organizational weaknesses, underscoring the importance of proper planning and safety protocols.
“This investigation underscores the critical role the CSB plays in identifying safety gaps and preventing future incidents,” said CSB Board Member Sylvia Johnson. “By thoroughly examining the causes of chemical incidents and issuing clear, actionable recommendations, the CSB helps protect workers, communities, and the environment.” CSB Chairperson Steve Owens added: “Toxic ammonia vapors can cause serious injuries and put lives at risk. Companies must ensure that toxic ammonia releases are discharged safely and that proper response procedures are in place.”
Following the investigation, the CSB issued multiple safety recommendations to Cuisine Solutions, including major improvements to the Emergency Action Plan. Additional recommendations were directed to the International Institute of All-Natural Refrigeration to strengthen industry guidance on preventing or mitigating two-phase ammonia releases.
The CSB, an independent federal agency, investigates incidents involving the release of extremely hazardous substances. Its mission includes conducting investigations, issuing safety recommendations, advocating implementation, reporting findings, and conducting hazard studies. Board members are appointed by the U.S. president and confirmed by the Senate. The agency does not issue fines or citations but provides guidance to companies, labor groups, industry organizations, and regulatory bodies such as OSHA and EPA.
