Recommendations for ammonia safety following fatal Kamloops incident

Vancouver, BC (January 26, 2023) – Technical Safety BC is urging owners, operators, and those who work with ammonia refrigeration systems to be more vigilant following an investigation into a fatal ammonia incident at an ice making facility in the Mount Paul Industrial Park located on Tḱemlúps te Secwépemc reserve in Kamloops.

The incident on May 26, 2022, led to a significant amount of ammonia being released into the surrounding area resulting in one fatality, multiple exposures, a local evacuation, and the temporary shutdown of nearby businesses.

Technical Safety BC’s incident investigation report found the primary cause of the incident was a failure to remove ammonia from the refrigeration system ahead of its disassembly. The investigation concluded that the ammonia release 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,” said Jeff Coleman, Director, Technical Programs, Technical Safety BC. “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.”

Between the initial shut down in 2015, and the incident in 2022, organizational changes, unclear communication, and incorrect assessments, were all contributing factors to the ammonia not being removed. In addition, previously cut piping and disconnected gauges identified pieces of the system as being empty. This led to the incorrect assumption that the entire ammonia system was empty, despite ammonia being found the day before the incident.

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

Based on the findings of this investigation, Technical Safety BC is sharing the learnings from this incident and is making three recommendations to seek improvements relating to the roles and responsibilities when dismantling refrigeration systems, and for the engagement of licenced refrigeration contractors when dismantling refrigeration equipment.

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:
• ammonia and oil are removed; and
• 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.

View the full Technical Safety BC investigation report.

A list of licensed refrigeration contractors is available through Technical Safety BC’s contractor look up tool (under ‘Boiler and Pressure Vessels’).

About Technical Safety BC
Technical Safety BC is an independent, self-funded organization that oversees the safe installation and operation of technical systems and equipment. In addition to issuing permits, licences and certificates, it works with industry to reduce safety risks through assessment, education and outreach, enforcement, and research.

Media contact
Technical Safety BC
778-773-4841
media@technicalsafetybc.ca