The document summarizes a heat exchanger rupture and ammonia release at a Goodyear tire plant in Houston, Texas that killed one person and injured six others. Key issues included deficiencies in emergency response procedures and accountability, incomplete maintenance that left isolation valves closed, and lack of over-pressure protection on the heat exchanger. The incident occurred when increasing steam pressure caused the heat exchanger to rupture after isolation and block valves prevented the ammonia from venting safely through relief valves.