WorkSafeBC has found the City of Fernie and CIMCO Refrigeration violated workplace laws in the lead up to and during their handling of the fatal gas leak at Fernie Memorial Arena last year.
In a damning report released on Wednesday afternoon, the agency identifies eight violations of the Workers Compensation Act and Occupational Health and Safety Regulation by the City of Fernie.
These include failing to conduct regular inspections of the workplace to prevent unsafe working conditions and failing to develop, and implement an exposure control plan for ammonia in the workplace.
WorkSafeBC also identified two violations by Toromont Industries Ltd. (CIMCO Refrigeration) for failing to protect the health and safety of CIMCO workers, including allowing maintenance work to be performed prior to ensuring the effective mitigation and control of all workplace hazards present in the workplace.
In addition to the violations, the City and CIMCO were told to refer to 11 and two sections of the Act respectively.
These violations could lead to enforcement action.
According to a press release issued on Wednesday, WorkSafeBC is currently considering the findings of the incident investigation report to determine appropriate enforcement action.
What caused the arena tragedy?
WorkSafeBC’s report confirms Technical Safety BC’s findings that the incident was caused by a small hole within a curling chiller, which allowed ammonia to mix with the brine solution and resulted in equipment failure when the plant was put into service.
WorkSafeBC responds to all reported workplace incidents that result in the death or serious injury of a worker, gathering and analyzing information to identify health and safety deficiencies, and the underlying factors that made these conditions possible.
It found efforts to remedy the “upset condition” of the curling chiller and get the refrigeration system running again did not address the ammonia containment leak.
Instead, they increased the risk to workers of ammonia exposure.
“These hazardous conditions were not fully considered, identified or mitigated by the occupational health and safety programs (the City of) Fernie and CIMCO had developed to protect workers from workplace hazards associated with working around and repairing ammonia refrigeration systems,” states the report.
WorkSafe found indications of an ammonia leak six months prior to the incident.
The agency said the City did not have a system in place to address or assess the potential safety hazards associated with aging equipment during start-up, operation or when shutting down the equipment in an upset condition.
CIMCO also did not provide the City with health and safety direction or caution against restarting the ice plant, instead directing additional monitoring of the system.
WorkSafeBC identified several contributing factors in the arena tragedy:
1. Health and safety systems did not mitigate risks to workers
The City of Fernie did not conduct a workplace health and safety inspection or incident investigation after the initial breakdown of the refrigeration system.
WorkSafeBC also found important information was not communicated within decision-making groups, contingency and action plans were not developed to address hazardous conditions that were known to exist, and workers were not informed of the new hazards associated with their assigned job duties.
“The inability of Fernie’s occupational health and safety program to detect and correct the initial indications of an ammonia leak six months prior to the incident, allowed hazardous workplace conditions to develop and continue unchecked up to the time of the incident,” states the report.
WorkSafeBC also found CIMCO did not have a stand-alone safe work procedure to mitigate the hazards to workers when dealing with refrigeration equipment in an upset condition.
2. Incident response measures were not present
WorkSafeBC’s report states that when the mechanical failure occurred and high concentrations of ammonia gas were released, City firefighters have already been dismissed and the alarm systems disabled.
The agency said there was no mechanism in place to alert any party that a serious incident had occurred and workers in the room were not wearing adequate personal protective equipment for the exposure levels they were being exposed to.
“When monitoring systems were removed from service while the workers conducted maintenance on the compressor, interim measures should have been implemented to ensure that the workers in the room had back-up assistance at the ready in case of further toxic gas release,” states the report.
At the time of the leak, the City had not reviewed emergency procedures or conducted practice drills “for many years prior to the incident”, which meant the responding workers were unfamiliar with procedures and important provisions were overlooked.
3. Manufacturing process fostered preferential corrosion
WorkSafeBC found the welding method employed during the manufacture of the chiller tubes was also a contributing factor in the Fernie arena tragedy.
This particular method allowed for deposits of unwanted porous iron oxide to build up along the welded seams, making them susceptible to higher-than-average corrosion in the presence of chemicals containing chlorides, such as calcium chloride brine using in the ice-making equipment.
Arena tragedy could have been worse
WorkSafeBC found more lives could have been lost in the arena tragedy due to the facility’s design.
According to the report, when the emergency ventilation system activated and venting occurred, released ammonia was drawn into the building’s HVAC system and recirculated into the facility through floor and wall ducting.
The compressor room was also not sealed, so hazardous vapours were able to migrate into other parts of the arena.
“Had these locations been occupied at the time of the incident, there could have been additional injury from exposure to the ammonia by workers and other people inside the arena,” states the report.
“There was no perimeter security or watch personnel to prevent inadvertent exposure to the ammonia by other workers or the general public.”
Read the full report here.
Earlier The Free Press reported:
An investigation into the Fernie arena tragedy has found occupational health and safety systems did not mitigate risks to three men who died after being exposed to ammonia at the facility.
Look back: Hundreds attend community memorial
WorkSafeBC also determined incident-response measures were not present when Lloyd Smith, Wayne Hornquist and Jason Podloski were performing maintenance on ice-making equipment at the arena, and this was a contributing factor to their deaths.
The agency has released its incident investigation report into the deadly ammonia release at the arena on October 17, 2017.
It aims to identify the cause of the incident, including contributing factors, so that similar incidents can be prevented from happening in the future.
WorkSafeBC’s findings confirm Technical Safety BC’s report, which stated the gas leak was caused by a small hole within the chiller, which allowed for ammonia to mix with the brine solution.
“When the compromised refrigeration equipment was put into service it failed, exposing three workers to a lethal concentration of ammonia,” said a press release issued by WorkSafeBC on Wednesday afternoon.
A contributing factor was the manufacturing process of the chiller tubes, which fostered corrosion.
The report also notes that curling rink chiller was past its life expectancy.
“It had been in operation for approximately 30 years, while the industry norm for this design of chiller ranges from 20 to 25 years,” read the WorkSafeBC press release.
More to come.