A deadly ammonia leak in Fernie, B.C. last fall was caused by the decision to operate an ice chilling system with a known leak, according to a new report.
The deadly event claimed the lives of three men. The victims included City of Fernie employees Wayne Hornquist and Lloyd Smith and refrigeration contractor Jason Podloski of Turner Valley, Alta.
According to the report from Technical Safety B.C., staff at the Fernie Memorial Arena identified a small hole in a metal tube in the arena’s ammonia-chilled heat exchanger in the summer of 2017.
WATCH: A deadly ammonia leak at a Fernie hockey rink last October was caused by an ice chilling system with a known leak, according to a report. As Christa Dao explains, the system was brought back in service just one day before the fatal leak.
The system was taken off-line until Oct. 16, when it was returned to service with the decision to monitor it.
LISTEN: Deadly Fernie ammonia leak caused by decision to operate leaky chiller: Report
The day after the system was brought back online, ammonia began leaking into a brine solution used to cool the arena’s ice surface, and then into the machine room.
“While the equipment failures originated from a small hole in a curling chiller tube, Technical Safety B.C. has concluded that the cause of this incident was a decision to operate that leaking chiller,” said Jeff Coleman, Technical Safety B.C. director of risk and safety knowledge.
The leak set off an alarm, and the chiller system was shut down. But ammonia continued to leak, according to the report.
WATCH: Investigators answer questions about deadly ammonia leak
Over the next five hours it entered the brine, expanding, building up pressure and eventually bursting a pipe fitting.
The resulting rapid leak of ammonia created ammonia levels “well above” those considered “rapidly fatal,” according to the report.
The report found that the arena’s venting system couldn’t have handled the extremely high levels of accumulated ammonia.
WATCH: New report details what happened at the Fernie Memorial Arena in October 2017
It also found workers responding to the crisis were unprepared for what they were dealing with.
“Once the leaking chiller returned to operation additional actions and decisions associated with the shutdown configuration were a response to cascading failures and beyond the scope of training and understanding of those involved.”
WATCH: Coverage of the tragedy in Fernie on Globalnews.ca
According to the report, the City of Fernie had identified concerns about the chiller as far back as 2010 when the system reached the end of its service life.
But it found that while the city had scheduled funding to replace the system in 2013, that was deferred until 2014 and then deleted from the city’s capital plan.
The report has also made 18 recommendations in order to prevent a repeat of the tragedy in the future.
They include new owner maintenance programs, especially related to aging systems, identification of leak hazards and professional disclose of such hazards, and better training of owners’ representatives, operators and mechanics.
Victim’s friend speaks out
One of the victims, Lloyd Smith had previously worked in Okotoks, Alta. His friend Stuart Ray said the report does provide some closure for those who knew him.
“There’s a lot of despair and sadness as a result of Lloyd’s loss,” Ray said.
Ray is also executive director of the Alberta Association of Recreation Facility Personnel. He said he wasn’t surprised by the findings in the report.
“When you look at the aging infrastructure in Canada and North America wide, there is a serious issue across municipalities not only on recreation side of things, like arena and pools but also with bridges and other linear things across the country,” he said.
Ray said he hopes the report prompts other organizations to heed the warnings of experts about replacing aging infrastructure.
Province responds to report
B.C.’s Minister of Municipal Affairs and Housing Selina Robinson issued a statement saying that Technical Safety BC will work with communities and stakeholders to “advance the recommendations,” and implement safety improvements for ice rink refrigeration systems.
“The recommendations, for arena owners, maintenance contractors, training providers, local B.C. governments and the Canadian Standards Association, will improve safety in ice-rink refrigeration systems throughout the province, so people can feel safe,” she said.
“This has been a very difficult process for the entire community of Fernie. I want to again extend my condolences to the three families who lost loved ones in the Memorial Arena tragedy last October.”
The case is believed to be the first fatal ammonia leak in Canada, but the gas has seeped out of refrigeration systems before, causing injuries in several cases.
A previous report from Technical Safety B.C., which oversees the installation and operation of technical systems like refrigeration and boiler systems, shows there were 40 reported “refrigerated release incidents” involving ammonia across the province between 2007 and 2015.
The report says 10 of the incidents included injuries.
-With files from Christa Dao and The Canadian Press