WorkSafeBC has completed its incident investigation report (IIR) into a catastrophic ammonia release at the Fernie Memorial Arena. On Oct. 17, 2017, three workers lost their lives while performing maintenance on ice-making equipment at the arena.

The primary purpose of WorkSafeBC’s investigation report is to identify the cause of the incident, including contributing factors, so that similar incidents can be prevented from happening in the future.

Cause of the incident
A pinhole developed in the refrigeration-system component, allowing for the intermixing of brine and ammonia, which compromised the refrigeration equipment.
When the compromised refrigeration equipment was put into service it failed, exposing three workers to a lethal concentration of ammonia.

Contributing factors include:
– Occupational health and safety systems did not mitigate risks to workers.
– Incident-response measures were not present.
– The manufacturing process of the chiller tubes fostered corrosion.

The report notes that the curling-rink chiller was past its life expectancy. It had been in operation for approximately 30 years, while the industry norm for this design of chiller ranges from 20 to 25 years.

Here is WorksafeBC’s Fernie Memorial Arena Incident Animation:

Prevention initiatives
WorkSafeBC has incorporated the findings of the investigation into its ongoing ammonia-related prevention efforts, including educating employers and contractors through targeted information sessions, outreach to municipal governments, online educational resources, and presentations to employer associations.

These prevention efforts are building on WorkSafeBC’s three-phase ammonia inspection initiative, which was launched throughout the province to address ammonia safety:

Phase one took place from November 2017 through January 2018, in collaboration with Technical Safety BC. All 223 arenas in the province were inspected, of which 181 arenas were using ammonia-based refrigeration systems.

Phase two of the inspection initiative focused on the activities of refrigeration contractors conducting installations, maintenance, and other activities involving ammonia systems.
Phase three is underway and is focusing on other industry sectors that use ammonia, such as food processing and industrial chemical manufacturing.

Next steps
In addition to determining the cause of an incident, the findings of a WorkSafeBC investigation may also result in enforcement action where violations of the Workers Compensation Act or the Occupational Health and Safety Regulation have occurred. WorkSafeBC is currently considering the findings of the IIR to determine appropriate enforcement action.

City of Fernie Statement
Fernie Chief Administrative Officer, Norm McInnis stated: “The City of Fernie still feels the loss of three valuable men. We know how essential it is to take worker safety seriously. Based on the findings of this and the TSBC report, we now all have the benefit of hindsight. We now know that mixing coolants, as led to the incident, creates a hazard – something no one in the industry knew before.

We continue to reflect on the learnings of this terrible accident. It compels us all to think about how to improve. While we can’t change what happened, we can do more to look holistically at all aspects of how our city functions in a way to make safety not just a goal we meet but a culture we embody. We want to particularly look at how we improve documentation and internal communications – two areas we agree with WorkSafeBC that could benefit from improvement.

We can also commit that the City of Fernie will do everything we can to help other municipalities learn from this. We have seen a number of arenas close due to similar coolant contamination issues, including in our area and we want to ensure it never happens again.

Although we don’t see that the report points out anything specific we could have done to prevent this tragedy, administration and Council will take time to review the report and orders in detail to learn from it.”

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