Technical Safety BC makes 18 recommendations to improve ice rink refrigeration systems safety

Technical Safety BC has made 18 recommendations to improve safety in ice rink refrigeration systems and prevent an incident similar to the fatal ammonia release event that occurred at the Fernie Memorial Arena on October 17, 2017. The incident at Fernie tragically resulted in three fatalities, as well as the evacuation of 95 residents from 55 nearby homes. 

The recommendations are based on the findings from Technical Safety BC’s investigation into the Fernie incident.  That investigation identified three areas where evidence indicates contributing factors leading to the incident and the impact to the arena and surrounding community:

  1. Failure of refrigeration system equipment;
  2. Operational decisions that contributed to the incident; and,
  3. Impact of inadequate ventilation and discharge systems following the incident.

The recommendations reach out to different stakeholders who can help make ice rink refrigeration systems safer including: plant owners, maintenance contractors, training providers, municipalities and the Canadian Standards Association. These recommendations seek improvements to:

  • owner maintenance programs and organizational design;
  • identification of leak hazards and professional disclosure of such hazards;
  • training of owners representatives, operators and mechanics;
  • secondary coolant system configuration and construction in anticipation of refrigerant leaks; and
  • public transparency and a culture of openness around technical systems.

The recommendations include the following:

  1. Include design, configuration and condition requirements into CSA B52-13 to ensure the secondary coolant portion of a system can safely withstand the effects of a refrigerant leak.
  2. Implement a refrigeration system maintenance program that addresses: wear-out / end-of-life; resources and approval & accountability.
  3. Add brine testing, analysis and interpretation to the training and qualifications of refrigeration operators, refrigeration mechanics and 4th class power engineers.
  4. Provide refrigeration system, maintenance program and worker qualification/skill awareness training to all employees and representatives responsible or involved with approving arena maintenance related activities or expenses.
  5. Improve training related to maintenance strategies and maintenance program awareness dealing with component wear-out and condition assessment so that graduates can effectively participate with a comprehensive program.
  6. Implement clear procedures that provide guidance and instructions to employees regarding the hazards associated with leaking chillers and required actions.
  7. Develop and implement generically applicable emergency situational guidance that can be taught and posted within mechanical rooms.
  8. Implement procedures for employees interacting with owners and operators to clearly disclose and refer items that are a cause for concern to refrigeration professionals with the necessary training to provide advice.
  9. Implement training and procedures for refrigeration system managers to identify the limitations of different technical qualifications associated with refrigeration systems and engage independent advisors for items considered a cause for concern.
  10. Incorporate safety risk assessments into asset management planning activities for all arena and curling refrigeration systems and mechanical rooms.
  11. Conduct an assessment of the organizational design and assigned resourcing for positions that are accountable for technical system management.
  12. Conduct an assessment and test of ventilation systems to evaluate effective internal ventilation of the mechanical room and external discharge in a manner that minimizes risk of exposure.
  13. Implement leak rupture ventilation requirements into CSA B52-13 that consider leakage scenarios, system performance and airflow within and outside of the mechanical room.
  14. Implement a requirement into CSA B52-13 to assess and verify by test that the ventilation systems effectively exhaust the mechanical room and externally discharge exhausted air in a manner that minimizes the risk of exposure.
  15. Re-evaluate the intended purpose of the emergency discharge provisions of CSA B52-13 Annex B and consider eliminating it from the code or discouraging its use.
  16. Inspect all emergency discharge piping and confirm that routing does not enter any spaces that present a risk to public safety.
  17. Review and amend guidance relating to the operation of an emergency discharge system such that specific scenarios where the benefits outweigh the risks are clearly identified and the necessary information to perform an emergency risk assessment is identified.
  18. Make publicly available the following information associated with management and oversight of regulated refrigeration systems at public assembly facilities (such as arenas):
    • refrigeration system maintenance programs for regulated equipment;
    • related capital budgeting plans for supporting maintenance programs;
    • assessment and audit criteria;
    • results of assessments and audits;
    • independent recommendations relating to the condition of equipment, including recommendations from maintenance contractors for repair or replacement; and,
    • any other information relevant to the assessment, audits and overall safety of the technical equipment and its management programs.

More details on these recommendations

 

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