UPDATE: City responds to investigation
The City of Fernie has released a statement following Technical Safety BC’s investigation into the tragic ammonia leak at Fernie Memorial Arena.
The City said they are committed to the health and safety of their employees.
“As a City we value and are committed to the health and safety of our employees and community members. The ammonia leak, and the subsequent loss of our valued colleagues, is one of the most tragic incidents to happen to our community. We still feel their absence deeply,” said City of Fernie Mayor Mary Giuliano.
“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.”
The City highlighted several findings of the report, including that their 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”.
In their statement, the City of Fernie did not comment on a section in Technical Safety BC’s report which states that the City of Fernie delayed replacement of the cooling plant, which the agency says was pivotal in the development of this incident.
In October 2010, seven years prior to the incident, the City of Fernie received a recommendation from their maintenance contractor to replace the curling system brine chiller due to its age. Analysis of evidence gathered during the investigation identified a series of key decisions during this seven-year period that contributed to the incident.
Potential influences of these decisions were identified, including:
A. facility management and organizational priorities;
B. failure to include safety risk criteria from aging infrastructure risk assessment;
C. operational management structure;
D. employee capacity and turnover;
E. incomplete maintenance planning; and
F. an industry practice of run-to-failure or run-past-failure for brine chillers.
I. Failure of refrigeration system equipment
II. Operational decisions that contributed to the incident
III. Impact of inadequate ventilation and discharge systems following the incident
“The City of Fernie initially scheduled funding to replace the curling brine chiller for 2013. This funding was deferred to 2014 and then deleted from further financial planning,” read the investigation report by Technical Safety BC.
“At the end of the 2016/2017 operating season, an ammonia leak was detected in the curling system, indicating a potential failure of the chiller. A decision was made to monitor the leaking chiller in the summer of 2017, followed by a decision to put the leaking chiller back into operation on October 16, 2017. Available evidence did not indicate that there was an awareness of any safety risk associated with the continued operation of the chiller by any parties involved.
“The decision to operate the leaking chiller is pivotal in the development of the incident. 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.”
Aging cooling system behind Fernie’s fatal ammonia leak needed replacing in 2010: report
The decision to operate a leaking chilling plant is what caused the fatal ammonia leak at Fernie Memorial Arena last October, according to Technical Safety BC.
Formerly the BC Safety Authority, the organization announced to a crowd of journalists in Vancouver on Wednesday that in the summer of 2017, ammonia was found in the brine of the chilling plant, which appeared to be leaking through a 2.2mm by 0.2mm hole along a corroding welded seam.
On Oct. 16, the refrigeration system was put back into operation in coordination with start of the curling season.
Technical Safety BC said that in 2010 a maintenance contractor recommended to the City of Fernie that the cooling plant needed replacement. A decision was deferred to 2014, and was eventually dropped from capital plans. By 2017, a hole had formed in a chilling tube, which released ammonia into the brine upon startup.
The group explained they did not discover any evidence that staff understood the safety risk that this 2.2mm hole presented.
Asked if staff were to blame for this incident, Technical Safety BC said their investigation does not look at or consider terms such as negligence.
A break down of the investigation:
Technical Safety BC’s investigation took place between October 2017 and July 2018, and looked at the factors that contributed to the ammonia leak.
The agency inspected, tested and analyzed the refrigeration system and components at Fernie Memorial Arena to determine the equipment that had failed.
It also identified relevant organizational and operational decisions that may have contributed to equipment failure.
Technical Safety BC then inspected and tested the ammonia detection, alarm, ventilation and discharge systems.
Its report is divided into three areas – equipment failure, operational and management decisions, and post incident ventilation of discharge.
Technical Safety BC director of risk and safety knowledge Jeff Coleman said the refrigeration system used at Fernie was typical of many in the industry.
“Ammonia was detected within the curling brine system during routine maintenance and testing in the spring and summer of 2017,” he said.
“Our investigation later found that the ammonia had leaked into the brine through a small hole in a tube within the curling system.”
The hole, measuring 2.22mm by 0.2mm, was located on a corroding welded seam.
In spite of the hole, the chiller was returned to operation on October 16 – the day before the incident.
“Shortly after returning to operation, ammonia leaked into the brine and was then released from the brine solution into the mechanical room through brine expansions tanks,” said Coleman.
“This led to an ammonia alarm at 3:53 a.m. on October 17.
“In response to the ammonia leak, the brine system and curling chiller were isolated and the refrigeration and brine systems shut down.”
Coleman said this shut down configuration was significant for two reasons.
“One, liquid ammonia was isolated within the curling chiller and two, the brine system was isolated so that expansion and ventilation of the brine was impeded.
“Ammonia continued to leak into the brine over the five hour period that followed.
“As the leak continued, ammonia concentrations rose within the brine close to the hole and the temperature of the brine in the chiller increased.
“This temperature increase led to elevated pressures within the brine system and chiller.”
However, the brine system was not designed to withstand this amount of pressure.
Coleman said rising pressure within the brine system eventually caused a pipe to burst within the mechanical room at the arena.
“The coupling separation suddenly depressurized the brine system and caused the ammonia and the brine in the piping to rapidly release into the mechanical room,” he said.
“As ammonia was released, it quickly expanded within the room reaching estimated concentrations that are considered well above rapidly fatal.”
Operational and management decisions
Coleman said that in October 2010, seven years prior to the incident, a City of Fernie maintenance contractor recommended replacing the aging curling chiller as it had “reached the end of its estimated service life”.
“The City of Fernie scheduled funding to replace that chiller in 2013,” he said.
“In 2013, the funding for the replacement was deferred to 2014 then subsequently deleted from capital plans.
“In the years that followed, the curling chiller replacement was represented as an objective rather than a scheduled expense.”
Ammonia was discovered in the brine of the chiller in the summer of 2017, indicating a leak within the chiller.
Coleman said at that time, a decision was made to monitor the leaking chiller, which as put back into operation on October 16.
Technical Safety BC found that once the chiller was returned to operation, additional actions and decisions associated with the shutdown configuration were a response to “cascading failures and beyond scope of training and understanding of those involved”.
“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,” he said.
Coleman said there were many contributing factors that led to the decision and condition of the equipment.
These include insufficient hazard awareness of leaking chillers and ineffective maintenance of aging equipment, and are summarized in Technical Safety BC’s report on the incident.
The Free Press team was live on Facebook to broadcast the news conference at 11 a.m. MDT, 10 a.m. PT.
A look back at last October:
On October 17, 2017, three workers - 59-year-old Wayne Hornquist, 52-year-old Lloyd Smith and 46-year-old Jason Podloski - died after being exposed to ammonia at the Fernie Memorial Arena.
Lloyd Smith was remembered for his passion and his smile. Smith, who was the director of leisure services at the City of Fernie was also a father, paramedic and pilot.
In June of the following year, a walking trail was named in honour of Wayne Hornquist.
Born and raised in Fernie, Hornquist spent 25 years as Chief Facility Operator for the City of Fernie, where he was known as “The Wizard” among his coworkers. His passions included hiking and gardening.
On Tuesday, July 24 - nine months after the arena tragedy - Technical Safety BC, formerly the BC Safety Authority, announced it would release the findings of its investigation into the gas leak.
The report will provide an overview of the incident, the scope of the investigation and key findings regarding contributing factors, as well as recommendations to prevent similar incidents from happening again.