Fatal incident review

Photo: CTV

Technical Safety BC thas just released its Investigation Report into the ammonia release at Fernie Memorial Arena on October 17, 2017.

This is believed to be the First incident of its kind in Canada
which resulted in three fatalities and the evacuation of 95 residents from 55 nearby homes.

The incident is believed to have resulted from a leak of ammonia into a secondary coolant – in this case brine – which led to pressurization in a pipe that resulted in the pipe coupling separation and a rapid release of ammonia into an enclosed room.

“Our report is focused on understanding the factors that led to the incident and providing recommendations to improve safety and prevent a similar tragedy,” said Janice Lee, Director of Safety Oversight at Technical Safety BC. “Since the incident occurred last year, Technical Safety BC has taken decisive action to advance the safety of ammonia refrigeration facilities in the province. We issued a province-wide Safety Order requiring all public occupancy ammonia refrigeration plants – including arenas – to test for ammonia leaks and shut down the system if necessary. All 185 facilities in British Columbia have fulfilled the obligation and are compliant.”

Photo: Technical Safety BC

The report provides an overview of the incident, the scope of the investigation, and key findings regarding contributing factors. Technical Safety BC also made 18 recommendations to further improve safety in ice rink refrigeration systems, and discussed a number of regulatory actions taken in recent months to prevent similar incidents.  

“This has been a terrible loss for the families of the three workers and had a deep impact on the whole community of Fernie,” said Quinn Newcomb, Interim Vice President of Human Resources, Learning and Engagement. “We will work with stakeholders to enhance the safety system to prevent a similar tragedy from ever happening again.”

Technical Safety BC has made 18 recommendations to prevent a recurrence of this type of incident and improve safety in ice rink refrigeration systems throughout BC. These recommendations seek improvements to:

• owner maintenance programs, especially in relation to aging equipment
• identification of leak hazards and professional disclosure of such hazards
• training of owners’ representatives, operators and mechanics; and, secondary coolant system configuration and construction.