Image Credit: CFJC Today

By Michael Reeve

FATAL AMMONIA LEAK

Poor communication led to fatal 2022 ammonia leak in Mount Paul Industrial Park: Technical Safety B.C.

Jan 26, 2023 | 9:04 AM

KAMLOOPS — A Technical Safety B.C. report into a fatal ammonia leak that occurred on May 26, 2022 determined that the primary cause of the incident was failure to remove ammonia from a refrigeration system ahead of it’s disassembly.

The incident occurred at Arctic Glacier, an ice-making facility in the Mount Paul Industrial Park.

The significant ammonia leak resulted in one death, as well as multiple exposures, a local evacuation and the shutdown of nearby businesses.

“Technical Safety BC’s incident investigation report found the primary cause of the incident was a failure to remove ammonia from the refrigeration system ahead of its disassembly. The investigation concluded that the ammonia release occurred when a ball valve holding back pressurized ammonia for the entire system was opened. However, those working on the disassembly understood the system had been previously emptied,” reads a statement from Technical Safety B.C.

“Our safety system is built on the foundation of ensuring that work associated with hazards is only completed by persons with the necessary skills and knowledge,” said Jeff Coleman, Director, Technical Programs, Technical Safety B.C. “Unfortunately, when this equipment was shut down in 2015, the ammonia was not removed. Then in 2022, a licensed refrigeration contractor was not engaged to prepare the equipment for final disassembly.”

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“Between the initial shutdown in 2015, and the incident in 2022, organizational changes, unclear communication and incorrect assessments, were all contributing factors to the ammonia not being removed. In addition, previously cut piping and disconnected gauges identified pieces of the system as being empty. This led to the incorrect assumption that the entire ammonia system was empty, despite ammonia being found the day before the incident,” continues the report.

On May 25, 2022, the day before the fatal accident, crews working to disassemble the refrigeration system discovered ammonia in the system.

“Ammonia was encountered while cutting a pipe connected to the P24 refrigeration system. After encountering ammonia, it was decided that the ammonia should be removed by the process of purging. Purging, in this instance, is the act of intentionally removing ammonia from the system by dissolving it in water,” reads the report.

Crews purged the ammonia for upwards of 16.5 hours. However, on the morning of the incident, when crews arrived they were unable to enter the facility due to a strong smell of ammonia.

“Thursday morning [May 26, 2022], we got there at 6:45, the boys went to open the roller door and it was such a potent smell in the building. [The broker] and [buyer] cracked that one valve open; it was kept bleeding overnight outside to try and completely get rid of all this stuff, but it was toxic in that building. We couldn’t get in, when they had opened that room, it just filled in the room more than anything. The broker went in and closed that valve again and we had to sit outside for an hour before we could even go in to do any work because it was such a strong smell still in that building and we couldn’t get in there, hurting our lungs and eyes,” reported an unidentified rigger on the job site.

File Photo (Image Credit: CFJC Today)

When crews were finally able to re-enter the building an altered piece of equipment led to the rapid release of ammonia.

“At some point, the (refrigeration) system was altered by Refrigeration Mechanic A to include a quarter turn ball valve that operates in a binary manner (on-off). When that same valve was opened, the ammonia release was rapid and uncontrolled,” reads the report. “The (systems) receiver’s dedicated pressure relief valve was likely removed during an earlier modification to the system. When the ammonia was later isolated within the receiver (pumped down), the receiver was in a hazardous state which could have resulted in an over pressurization failure at any point after the ammonia was isolated in the receiver in 2016.”

Technical Safety B.C.’s investigation found that the valve did not malfunction in the incident and the receiver would have been capable of holding pressure.

Technicial Safety B.C. released three recommendation in its report.

1. It is recommended that when planning for and facilitating the final shut down and disassembly of refrigeration equipment, owners and managers directly engage a licenced contractor to validate:
   1. ammonia and oil are removed; and
   2. equipment is ready for safe disassembly and transportation.
2. It is recommended that persons who previously held, or currently hold a technical qualification do not counsel unqualified persons to do regulated work. Qualified persons are reminded that the Safety Standards Act and Regulations prohibit unauthorized persons from doing regulated work unless they are being supervised by a qualified person.
3. It is recommended that Canadian Standards Association (CSA) adopt or develop requirements for the dismantling, disassembly and/or decommissioning of refrigeration systems and equipment.
   File Photo (Image Credit: CFJC Today)