Questions remain over a critical funding decision that may have prevented the deaths of three men at Fernie Memorial Arena last year.
Last week, Technical Safety BC released the findings of its investigation into the fatal ammonia leak, which claimed the lives of City workers Lloyd Smith and Wayne Hornquist, and refrigeration technician Jason Podloski on October 17, 2017.
The men were exposed to the highly toxic gas while responding to an alarm triggered by a leak in the curling system chiller, which caused pressure to build up and a coupling pipe to separate, releasing ammonia into the mechanical room in an industry first.
Technical Safety BC examined relevant organizational and operational decisions that may have contributed to the incident, including a recommendation to replace the aging system seven years prior.
On October 5, 2010, Calgary refrigeration company Startec advised the City that the equipment was past its life expectancy and replacing it should be given “great consideration”.
“The average life for this chiller is 20 to 25 years and the age of this unit is at its peak,” wrote the sales representative, whose identity was redacted in Technical Safety BC’s report.
A replacement was initially budgeted at $57,000, however, seven years later, the system had still not been replaced and a small hole had formed within the chiller.
City of Fernie documents show the chiller replacement was deferred and eventually deleted from financial plans for capital spending from the 2014 and subsequent five-year financial plan for capital spending.
“In the years that followed, the curling chiller replacement was represented as an objective rather than a scheduled expense,” Technical Safety BC’s Director of Risk and Safety Knowledge Jeff Coleman told a crowd of journalists gathered at a press conference in Vancouver on July 25.
There were also several staffing changes in key management and operational positions relating to the arena in the time between the initial recommendation and the arena tragedy.
During seasonal maintenance in April/May 2017, ammonia was detected in the curling brine system, indicating a leak, which Technical Safety BC determined was caused by a 2.22mm by 0.2mm hole along a corroding welded seam.
A decision was made to monitor the leak and the chiller was returned to operation on October 16 in coordination with the start of the curling season, with replacement pegged for the following summer at an estimated cost of $250,000.
The following day, ammonia leaked into the brine solution and was released into the mechanical room, reaching estimated concentrations that Technical Safety BC considered “well above rapidly fatal”.
The agency did not find any evidence that staff understood the safety risks associated with the continued operation of the leaking chiller.
“Once the leaking chiller was put back into operation, additional actions and decisions were a response to cascading failures and were beyond the scope of training and situational awareness of those involved,” said Coleman.
“While the equipment failures originated from a small hole that occurred in chiller two, Technical Safety BC has concluded that the cause of this incident was a decision to operate that leaking chiller.”
Coleman said there were many lessons to be learned from this incident but two in particular stood out. “First, maintenance programs for refrigeration systems must address and alleviate the risks presented by aging equipment. And second, even very small leaks of refrigerant can indicate extremely hazardous situations,” he said.
Soon after the agency handed down its report, the City released a statement, which highlighted several findings, including that staff were trained to the highest levels available in the industry, that they were working with approved certification for their system at the time of the incident, and that there was no evidence to indicate that anyone was aware of any safety risk associated with the continued operation of the chiller.
The City added that, “Technical Safety BC compared our maintenance plan and contract to others in B.C. and determined it was consistent”.
“Despite working with an approved certification for our system at the time of the incident, today’s report points to opportunities to further improve safety standards for arena refrigeration plants, not only for Fernie but for communities across British Columbia so no one else will need to experience a similar tragedy,” said Fernie Mayor Mary Giuliano on July 25.
However, the City’s statement did not address the delayed replacement of the cooling plant, which Technical Safety BC said contributed to the incident.
As of press time, City staff had not provided further comment on the matter.
The Fernie arena tragedy prompted a province-wide inspection of ammonia ice and curling rinks, as well as a safety order that required owners to test secondary coolants for the presence of ammonia and report the results.
Prior to July, Technical Safety BC had completed physical inspections of 95 per cent of ice rink refrigeration sites with the remainder to be inspected in the weeks that followed.
It will work with industry and other agencies to advance its 18 recommendations and implement safety improvements for ice rink refrigeration systems across B.C.
To view the full report, visit Technicalsafetybc.ca/fernieincident.
RCMP investigation ongoing
A criminal investigation into Fernie’s fatal gas leak is ongoing.
The RCMP has confirmed it is still examining the events of October 17, 2017, when three men were killed after being exposedto ammonia at Fernie Memorial Arena.
However, it did not indicate when the investigation would be completed or findings handed down.
“These types of investigations are time consuming and investigators must always be mindful of gathering evidence in afashion that is acceptable to the courts,” said B.C. RCMP Communications Services Senior Media Relations Officer SeniorSergeant Annie Linteau.
“Throughout this investigation, the RCMP, Technical Safety BC and WorkSafe BC have conducted parallel, but independentinvestigations into this incident.”
It comes after Technical Safety BC released the findings of its investigation, which aimed to determine the cause of the gasleak and provide recommendations to improve refrigeration system safety.