Fernie Investigation Report

Persona

Technologies

On October 17, 2017, there was an ammonia release at the Fernie Memorial Arena which tragically resulted in three fatalities, as well as the evacuation of 95 residents from 55 nearby homes.

On July 25 Technical Safety BC held a press conference and released its Investigation Report into the ammonia release. The report provides an overview of the incident, the scope of the investigation, and key findings regarding contributing factors. Technical Safety BC also made 18 recommendations to further improve safety in ice rink refrigeration systems, and discussed a number of regulatory actions taken in recent months to prevent similar incidents.

 

Incident Investigation Report

Incident Overview & Site Description
Report Summary
Scope of Investigation
Investigation Findings I: Failure of refrigeration system equipment
Investigation Findings II: Operational decisions that contributed to the incident
Investigation Findings III: Impact of inadequate ventilation and discharge systems
Conclusions
Recommendations

Appendices

Failure of refrigeration system equipment
A - Engineering Analysis - Cold Dynamics Ltd. 
B - Valve Positions - Brine and Ammonia Systems 
C - Site Description and Scene Documentation
D - Ammonia Odour Map - Witness Reports
E - Laboratory Analysis Report - System Component Failure Evaluation
F -Curling System Brine Analysis Reports
G - Alarm Monitoring Company Activity Report - Fernie Memorial Arena
H - Electrical Power Consumption Analysis - Mechanical Room - Fernie Memorial Arena
I - Spray Residual Analysis - Mechanical Room
J - Fluid Sample Analysis - Post Incident - Fernie Memorial Arena
K - Brine System Pipe Coupling - Manufacturer's Catalogue Page

Operational decisions that contributed to the incident
L - Recommendations to Replace Curling Chiller in 2010 and 2011
M - Financial Analysis - Fernie Memorial Arena Capital Spending
N - Curling Chiller Replacement Planning Analysis
O - Employee Turnover Analysis - City of Fernie
P - Capital Spending Request - Curling Brine Chiller - August 17, 2017 - City of Fernie
Q - Fernie Memorial Arena Employee Certification and Staffing Summary
R - Organization Chart - City of Fernie (December 31, 2016)
S - Director of Leisure Services Job Description - City of Fernie
T - Leaking Chiller Communications Review
U - Training and Qualification Review of Persons Involved wit Refrigeration Systems
V - Arena Surveys: Maintenance Programs and Leaking Chillers
W - Cimco Web Article - Brine Maintenance for Rinks

Ventilation and Emergency Discharge Systems
X - CSA B52-13 Code Rules Relating to Doors and Ventilation
Y - CSA B52-13 Code Rules Relating to Emergency Discharge

Other Ammonia Resources

Questions? Please contact media@technicalsafetybc.ca.