A couple of KEY items, reading between the lines:
- Discharge from the PRV was HORIZONTAL through a horizontal tee, not UPWARDS, and UNOBSTRUCTED.
- The release was OUTSIDE, yet the facility evacuated, and some workers evacuated into the NH3 cloud that had formed (see image below)
- Only 170 pounds of NH3 was released.
- Forty people working at the Cuisine Solutions facility were evaluated at various local medical facilities. Of those, four were admitted to local hospitals, with one admitted to the Intensive Care Unit
https://www.csb.gov/assets/1/6/cuisine_solutions_investigation_update_-_final_to_publish1.pdf