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CSB Investigation
Report No. CSB-CUISINE-AMMONIA-2024
2024
Safety Safety
Cuisine Solutions 氨制冷系统泄漏
Cuisine Solutions, Inc., Sterling, Virginia
Related equipment → Centrifugal compressor (centrifugal_compressor)Related equipment → 压力容器/缓冲罐/分液罐/闪蒸罐 (Pressure Vessel) (压力容器/缓冲罐/分液罐/闪蒸罐 (Pressure Vessel))
0Fatalities
0Injuries
LeakageMechanism code OTH
⌗Failure Mode · ISO 14224 Mapping
Damage mechanism (recorded in KB)
LeakageOTH
ISO functional code (as recorded)
ISO 14224:2016 functional failure code
OTH · Other
ISO OTH — Other.
1What Happened
氨制冷系统泄漏，约 40 人送医评估；压缩机/压力容器密封与气体检测不足
2Root Cause
氨制冷系统（PSM 高危化学品）机械密封与泄漏监测缺陷；应急通风与撤离预案不足
3Reliability Lessons (from investigation root cause)
- The 'Root Cause' above is the core lesson of this accident; not split further.
4Associated Failure Mechanisms (Keywords)
氨 制冷 泄漏 压缩机 中毒 制冷系统 气体检测
About the Failure-Mode Code (click to expand)
The recorded code OTH is an ISO 14224:2016 functional failure code (describes what the equipment failed to do). The damage mechanism (how it failed) is shown in the Mapping block above. The two are distinct dimensions in ISO 14224.
5Evidence Source (transparent)
Authority：U.S. Chemical Safety and Hazard Investigation Board (CSB)
Official Report：www.csb.gov ↗
Data Verification：url_verified_csb_investigations_list_2026-08-07（事故 2024-07-31 / 终报 2025-09-25）
↗Related Failure Modes · Traceability