Failure to remove ammonia prior to system disassembly caused fatal ammonia release

Incident Investigation

Failure to remove ammonia prior to system disassembly caused fatal ammonia release

May 26, 2022

Boiler, PV and Refrigeration

Reference Number:

II-1381615-2022 (#28065)



Location: Kamloops

Regulated industry sector: Boilers, Pressure Vessel & Refrigeration - Refrigeration system

Incident overview

An ammonia release at an ice making facility in the Mount Paul Industrial Park located on Tḱemlúps te Secwépemc reserve in Kamloops resulted in one fatality, multiple exposures, a local evacuation, and the temporary shutdown of nearby businesses. Our investigation found that the primary cause of the incident was a failure to remove ammonia from the refrigeration system ahead of its disassembly.

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