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Investigators blame 'unclear communication, incorrect assessments' for fatal ammonia leak

Fatal leak was human error

Technical Safety BC has concluded its probe of a fatal ammonia leak at a Kamloops ice-making facility last May, and a communication breakdown is to blame.

The May 26 leak resulted in the death of one person while three others were sent to Royal Inland Hospital.

In a news release, Technical Safety BC said the ice-making facility, in the 700-block of Sarcee Street East in the Mount Paul Industrial Park, was initially shut down in 2015.

According to the investigation report “organizational changes, unclear communication and incorrect assessments” resulted in the ammonia not being removed between 2015 and 2022.

“Unfortunately, when this equipment was shut down in 2015, the ammonia was not removed," Jeff Coleman, director of technical programs for Technical Safety BC, said in a statement.

"Then in 2022, a licensed refrigeration contractor was not engaged to prepare the equipment for final disassembly.'

Coleman said the safety system is “built on the foundation of ensuring that work associated with hazards is only completed by people who have the correct skills and knowledge.”

According to Technical Safety BC’s report, the ammonia equipment was last operated in December 2015, and a portion of the system was removed in 2018. Workers who started final removal of the remaining facility equipment in 2022 thought the system had been previously emptied.

Technical Safety BC said some piping and disconnected gauges identified parts of the system as being empty, which led workers to believe the entire ammonia system was empty despite ammonia being found the day before the incident.

According to Technical Safety BC, the ammonia release happened when a ball valve holding back pressurized ammonia for the entire system was opened.

This resulted in a “significant amount of ammonia” — between 1,300 and 1,645 pounds, according to Technical Safety BC — released into the atmosphere.

The investigation found there wasn’t any physical failure of any piece of equipment within the ammonia system.

Emergency crews were called to the incident at about 10:30 a.m., after which nearby streets were temporarily shut down and neighbouring businesses were closed.

According to Technical Safety BC’s report, the ammonia leak resulted in one fatality, 14 people exposed to ammonia, three sent to hospital, a local evacuation and an explosion.

“This is a traumatic event for everyone involved. Our condolences go out to the loved ones of the deceased and our thoughts are with those who were exposed, witnessed or were otherwise impacted by this tragic incident,” Coleman said.

He said Technical Safety BC will work to enhance the safety system and stop similar accidents from happening in the future.

Technical Safety BC said it urges those who work with ammonia refrigeration systems to be vigilant, and ensure only people with necessary skills and knowledge perform hazardous work.

The report said a licensed contractor must make sure ammonia and oil have been removed from a system and that equipment is ready for disassembly.



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