Fernie Investigation Report, Findings and Recommendations

Incident Investigation

Fernie Investigation Report, Findings and Recommendations

October 17, 2017

Boiler, PV and Refrigeration

Reference Number:


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, 2018, 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.


Download the Incident Investigation Report


Fernie-Specific Materials


Media Release
Fact Sheet
Media Press Conference Scripts

Learn about the ongoing work we are doing to improve the safety of the technical equipment we regulate in British Columbia.




Findings & Recommendations for Refrigeration Owners & Operators
Transcript of Q&A provided during the webinar
Findings & Recommendations for Refrigeration Contractors/Mechanics


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 with 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


Questions? Please contact media@technicalsafetybc.ca.