Anhydrous ammonia is the most common EPA RMP and OSHA PSM covered chemical in facilities throughout the United States. Using the CSB’s recently published report on the Cuisine Solutions ammonia release that occurred in 2024 as a case study, this presentation explores the ways in which atmospheric releases from pressure relief valves in ammonia service can present a hazard to personnel. Additionally, relief discharge modeling is presented to characterize the critical parameters affecting the safety of atmospheric relief discharge for anhydrous ammonia systems.