Technical Safety BC says a combination of staffing changes, communication failures and the use of uncertified contractors led to a deadly leak at the Arctic Glacier ice-making plant in the Mount Paul Industrial Park last May.

In a report released Thursday, it says investigators have determined that failure to remove ammonia from the refrigeration system ahead of its disassembly was the primary cause of the “significant” leak that killed one man in his 60s on May 26, 2022.

Between 1,300 and 1,645 pounds of ammonia was released directly into the atmosphere that day as 14 other people needed treatment with a number of nearby businesses also forced to temporarily shutdown while emergency crews were responding.

TSBC also says another 1,000 pounds of ammonia was likely purged through water and released into the parking lot between May 25 and 26, 2022.

The report says the fatal leak occurred when a ball valve holding back pressurized ammonia for the entire system was opened. However, those working on the disassembly understood the system had been previously emptied.

“Our safety system is built on the foundation of ensuring that work associated with hazards is only completed by persons with the necessary skills and knowledge,” Jeff Coleman, Technical Safety BC’s Director of Technical Programs said.

“Unfortunately, when this equipment was shut down in 2015, the ammonia was not removed. Then in 2022, a licensed refrigeration contractor was not engaged to prepare the equipment for final disassembly.”

The agency says there were several contributing factors that led to this incident, including miscommunication, staffing changes, and a failure to involve a licensed refrigeration contractor to conduct a complete assessment for the presence of ammonia.

“This is a traumatic event for everyone involved. Our condolences go out to the loved ones of the deceased and our thoughts are with those who were exposed, witnessed, or were otherwise impacted by this tragic incident,” Coleman added.

“We will work with stakeholders to enhance the safety system to prevent a similar incident from happening again.”

Technical Safety BC has released three safety recommendations – listed below – urging owners, operators, and people who with ammonia refrigeration systems to be more vigilant.

You can read the entire Technical Safety BC report here.

Key learnings:

• Leading up to the incident, workers unfamiliar with ammonia relied on the guidance of previously qualified refrigeration mechanics. This resulted in the work continuing when it likely would have otherwise been stopped.
• Only those with the necessary skills and knowledge should be conducting activities with hazardous work. This principle applies throughout the life cycle of regulated systems, including the stage of dismantling and decommissioning.
• Licensed contractors must validate that ammonia and oil have been removed from a system and that equipment is ready for disassembly and transportation.

Recommendations:

1. It is recommended that when planning for and facilitating the final shut down and disassembly of refrigeration equipment, owners and managers directly engage a licenced contractor to validate:
   1. ammonia and oil are removed; and
   2. equipment is ready for safe disassembly and transportation.
2. It is recommended that persons who previously held, or currently hold a technical qualification do not counsel unqualified persons to do regulated work. Qualified persons are reminded that the Safety Standards Act and Regulations prohibit unauthorized persons from doing regulated work unless they are being supervised by a qualified person.
3. It is recommended that Canadian Standards Association (CSA) adopt or develop requirements for the dismantling, disassembly and/or decommissioning of refrigeration systems and equipment.