Ice Rink Safety Series: Part 1 of 3
October 17th marks the one-year anniversary of the Fernie Memorial Arena ammonia incident that resulted in three fatalities (Lloyd Smith, Wayne Hornquist and Jason Podloski) and the evacuation of 95 residents from nearby homes. Each man is missed by friends and family, and our sincere condolences go out to them.
The incident at Fernie Memorial Arena has been investigated by the RCMP, WorkSafe BC and Technical Safety BC. The reports from these investigations will be used to transform workplaces across the country that use ammonia. In addition to determining cause of incident, ammonia-prevention education and outreach, the findings may also result in enforcement actions.
What Happened at Fernie Memorial Arena?
WorkSafeBC, the regulator for occupation health and safety in BC, is mandated by legislation to investigate workplace incidents. The primary focus of an incident investigation is to identify the cause of the incident and contributing factors. This investigation is released as a report so that similar accidents can be prevented from happening in the future. The WorkSafeBC incident report for Fernie Memorial Arena was recently released. This report is a part of the three-phase ammonia report will transform ice rink safety across the province to prevent ammonia-related incidents.
Fernie Memorial Arena consists of a curling rink and a hockey rink separated by a common area. The common area includes a large compressor room, where the refrigeration system is located.
An important component of the refrigeration system is the brine chiller, this helps create ice for arena surfaces. It is a large cylinder filled with ammonia. Within the cylinder are smaller tubes through which warm brine passes. The ammonia in the cylinder evaporates as it boils, cooling the brine as it circulates through the tubes. A pinhole in one of these tubes caused the incident at Fernie Memorial arena.
Fernie Memorial Arena Ammonia Incident Report
The pinhole developed in one of the brine chillers cooling tubes due to corrosion over time. The pinhole was not repaired during the summer shut down and caused ammonia and brine to mix together. This leak triggered the Automatic Ammonia Gas Detector alarm when the refrigeration system was started back up for the fall season.
WorkSafeBC released this Fernie Memorial Arena Incident Animation to summarize the findings of the incident investigation:
Fernie Memorial Arena Ammonia Incident Timeline
- Chiller started back into service
October 17, 2017
- Automatic Ammonia gas detector alarm triggered and sent to fire department and security company.
- 2 City of Fernie workers and 2 Firefighters arrive at the arena
- 1 worker and 2 Firefighters enter the compressor room wearing self-contained breathing apparatuses
- Inside the compressor room they observe the refrigeration equipment running and the alarm sounding. They noticed that the brine expansion tanks were shaking, and brine was sloshing out.
- Using hand help ammonia detectors, the firefighters noted that the ammonia level was at 300 parts per million, which is immediately dangerous to life and health
- City worker closed some of the ammonia system and brine valves, the shaking stopped.
- Firefighters vented the building and the ammonia levels were monitored at 50 parts per million
- The city worker isolated the leaking chiller and shut the system down
Between 4:30 am and 5:00 am:
- The firefighters were told they were no longer needed and left
- The city workers decided that the compressors should be restarted in an effort to save the hockey rinks ice, however, because the compressors oil has been contaminated with brine the oil would need to be changed first.
- They contacted an external contractor to change the compressor oil.
- Prior to the arrival of the refrigeration mechanics arrival, arrangements were made to turn the ammonia alarm into silent mode for the duration of the repairs.
- The refrigeration mechanic and the two city workers entered the compressor room to change the oil. They were not wearing personal protective equipment and they were not wearing personal ammonia exposure monitors.
- There was no back-up team and emergency responders were not present.
Around 9:30 am:
- The rising pressure within the brine system, due to the ammonia leak, exceeded the holding strength of a coupling, causing it to separate and spray the workers with a mixture of brine and ammonia.
- The high concentration of ammonia that was released into the room was not survivable. All three succumbed to the exposure.
How Does this Report Impact Ice Rink Safety?
The findings from this investigation have been incorporated into WorkSafeBC’s ongoing ammonia related prevention efforts, which includes educating employers and contractors, targeted information sessions, outreach to municipal governments, online educational resources and presentations to employer associations.
These ammonia prevention efforts are built out of the findings from WorkSafeBC’s three-part ammonia inspection initiative. The three part-initiative and 18 recommendations that have come from these findings will be discussed in Ice Rink Safety Part 2 .