Lack of emergency procedures contributed to Fernie arena deaths: WorkSafeBC

A WorkSafeBC investigation into an ammonia leak which killed three workers at a Fernie arena blames an aging refrigeration system and years of unheeded warnings for the tragedy.

The 74-page report cites failures on the parts of both the City of Fernieand CIMCO refrigeration contractor to ensure crucial safety procedures and risk assessment tools were implemented and understood by workers.

The investigation identified violations of the Workers Compensation Actby both the city and CIMCO, as well as multiple violations of Occupational Health and Safety Regulations by the city.

"Fernie had not reviewed the emergency procedures or conducted any practice drills for many years prior to the incident," the document says.

"When the upset condition occurred, and Fernie's workers responded to the first alarms, they were unfamiliar with the procedures, and important provisions prescribed by the procedures were overlooked."

'The curling club test looks bad!'

Lloyd Smith, Wayne Hornquist and Jason Podloskiwere all killed on Oct.17, 2017 while trying to fix the FernieMemorial hockey and curling arena's ice-making equipment.

Smith was Fernie's director of leisure services, Hornquist was the city's chief facility operator andPodloskiwas a refrigeration technician with contractor CIMCO Refrigeration.

Ammonia is used to make ice because of the fact it cools when turned into a gas.

The refrigeration equipment harnesses that property through a technique that passes tubes full of hot and cold brine through a pipe filled with ammonia. The tube full of hot brine turns the ammonia into gas in one part of the pipe, cooling the brine in another and creating ice in the process.

But the brine and ammonia should never meet.

According to the report, the arena's rink chiller had been in operation for 30 years. The industry norm for the life of the product ranges from 20 to 25 years.

WorkSafeBC says the former maintenance company said the chiller was past its life expectancy in 2010.

The report cites emails and tests indicatingthe presence of ammonia in the brine on several occasions in 2017, including one communication less than two months before the incident that said: "The curling club test looks bad! The brine line is also really corroded and leaking."

Those findings echo those of a report earlier this summer from Technical Safety B.C.

Firefighters on scene

According to the document, firefighters were called to the arena around four in the morningon the day of the incident after a worker said an alarm was indicating dangerously unsafe levels of ammonia.

Wearing specialized breathing equipment, they accompanied one of the workers into the room wherethe refrigeration unit was kept to investigate.

But once the refrigeration system was shut down, the firefighters left.

Smith, Hornquist and Podloski went back into the facility to fix the machine, silencing the ammonia alarms while they did so.

All three died when a pipe burst, spraying the men with ammonia. None were wearing the appropriate breathing equipment.

Later that day, an electrician who had been hired to work on the facility observed an open door and smelled ammonia. He entered, dragged one of the men out and began performing CPR, but it was too late.

'Poor communication and inconsistent attention'

As part of its investigation, WorkSafeBCanalyzed the health and safety programs being used by both the City of Fernie and CIMCOat the time of the incident and determined key elements of both were "either absent or ineffectively utilized."

The report says the city's written emergency response plans for ammonia leaks hadn't been reviewed for five years, and no evacuation test or drills had been held for three years.

"Poor communication and inconsistent attention to internal auditing, inspections, incident investigationand emergency practice drills allowed for the development of hazardous workplace conditions," the report says.

"A lack of adherence to the employer's own safe work procedures at the senior management level removed the benefit of interdepartmental oversight and resources."

The report also determined that while CIMCOhad an ammonia emergency response procedure and a means to assess risk, the procedures were not implemented "a significant factor in this workplace incident."

A month after the deaths, WorkSafeBCimplemented a plan to conduct inspections of all 223 arenas in B.C. More than 180 were found to be using ammonia-based systems.

In an emailed statement, Fernie'schief administrative officer, Norm McInnis, said city politicians and administration will take the time to review the report in order to learn from it.

"The City of Fernie still feels the loss of three valuable men. We know how essential it is to take worker safety seriously," McInnissaid.

"We continue to reflect on the learnings of this terrible accident. It compels us all to think about how to improve."