Kamloops Ammonia Release

Investigation report, findings, and recommendations

Kamloops ammonia release

An ammonia release on May 26, 2022, at an ice making facility in the Mount Paul Industrial Park located on Tḱemlúps te Secwépemc reserve in Kamloops 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.

Our investigation 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 to have been previously emptied.

Several contributing factors led to this incident, including miscommunication, staffing changes, and failing to involve a licensed refrigeration contractor to conduct a complete assessment for the presence of ammonia.

Based on our findings of this investigation, we are sharing our learnings and recommendations to prevent a similar occurrence.


Report summary

The safe dismantling of an ammonia system requires that the system be assessed, and ammonia and oil be removed prior to any disassembly work. Removal of ammonia and oil from a refrigeration system is regulated work that requires the knowledge and skills that a licensed contractor brings with qualified refrigeration mechanics. The investigation found that the failure to remove ammonia from the refrigeration system, prior to, or during disassembly was the primary cause of the incident.

  1. An incorrect understanding that ammonia had been removed during the shut-down of the system. This understanding was influenced by:
    • Changes in personnel and their assigned responsibilities.
    • Misunderstood communications regarding the work completed.
  2. Ineffective assessments to identify hazardous quantities of ammonia in the receivers. These assessments were affected by:
    • The exclusion of a qualified refrigeration mechanic from a dedicated role during the disassembly.
    • An irregular configuration of the equipment, which created the appearance the P34 system was empty.

Cause

  • The cause of the incident was the failure to remove ammonia from the refrigeration system, prior to, and during disassembly.

Contributing factors

  • Following equipment shutdown, there was an incorrect understanding that ammonia had been previously removed.
  • After discovering ammonia, assessments were ineffective in determining the location and quantity of ammonia.

Additional considerations

  • There was no physical failure of any component or assembly within the ammonia system.
  • The quarter turn ball valve resulted in the release of ammonia being rapid and uncontrolled. Environmental considerations
  • There was an increased risk of an overpressure failure from the P34 system for several years prior to the incident as a result of it being left full of ammonia with no connected relief valve.

Environmental considerations

  • 1000 lbs of ammonia was likely purged through water and released into the facility parking lot from the P24 system between May 25 and 26, 2022.
  • During the incident on May 26, 2022, between 1300 and 1645 lbs of ammonia was likely released directly into the atmosphere

  • A functioning exhaust system may have reduced the probability of an explosion occurring after the release.

  • 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.

Based on the findings of this investigation, we’re making three recommendations to seek improvements towards the roles and responsibilities when dismantling refrigeration systems, and for the engagement of licenced refrigeration contractors when dismantling refrigeration equipment.

Recommendation 1: to owners and/or managers of refrigeration systems:

  • 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.
    • Equipment is ready for safe disassembly and transportation.

Recommendation 2: to persons who hold or previously held a technical qualification:

  • 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.

Recommendation 3: to the Canadian Standards Association (CSA):

  • It is recommended that CSA adopt or develop requirements for the dismantling, disassembly and/or decommissioning of refrigeration systems and equipment.

Download the Incident Investigation Report

The following appendices are referenced throughout the report and provide supporting information:

A - Safety Standards Act, regulations and codes 
B - Site and equipment 
C - Roles 
D - Invoices, quotes and scope of work 
E - Fire department call out notes (2016) 
F - Practice and awareness study 
G - Correspondence 
H - Ammonia purge timeline 
I - Engineering analysis by Laporte Engineering Ltd 
J - Complete climate control report 
K - Vogt ice making machine manual 
L - Valve specification sheet
M - Leak check report
N - Acuren laboratory analysis report

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