Lack of proper assembly and torque leads to blown out gasket leading to ammonia leak from heat exchanger

Image 1 No lock washer on bolts

On the plate heat exchanger, a machined nut backed off on the flange bolt that holds the gasket in place. This caused part of the gasket to blow out resulting in ammonia (NH3) to leak into the machine room. The machinery room alarm was activated.  Upon inspection, the following failures were found:

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