Cloud of ammonia escaping the facility (Image Credit: TSBC)

By Michael Reeve

FATAL AMMONIA LEAK

Technical Safety B.C. report outlines 3 recommendations following 2022 fatal ammonia leak in Kamloops

Jan 26, 2023 | 4:10 PM

KAMLOOPS — A Technical Safety B.C. (TSBC) 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.

The TSBC report noted several contributing factors to the fatal accident last May, including miscommunication, staffing changes and failing to involve a licensed refrigeration contractor.

Miscommunication comes in thanks to the more than half-decade span of time from when the refrigeration units were de-commissioned in 2015 to disassembly in 2022.

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“Due to a number of factors, there were miscommunications that occurred and misunderstandings that left those remaining and working with the equipment to believe that the ammonia had been removed, when it in fact wasn’t and that is the impact that time can have,” Jeff Coleman, Director of Technical Programs for Technical Safety B.C., told CFJC Today.

The day before the incident, workers on scene discovered ammonia in one of the two tanks. That led to the team purging the ammonia into water, using a black barrel and hose, over the course of 16 hours.

After that discovery, the crew incorrectly believed there was no more gas in the system after conducting an assessment of the site. The report found those assessments were ineffective due to the exclusion of a qualified refrigeration mechanic.

“If work requires a special skill to put it together and to maintain it, it requires that special skill to take it apart or at very least to properly assess it and make sure and validate that it is safe for other to work on,” added Coleman.

When crews arrived back on site, the day of the incident, they were unable to enter the building due to a pungent smell of ammonia.

“It created a problem for the plans that were starting that day and it took some time for them to ventilate the building sufficiently to go in and resume those activities. Unfortunately, one of those vessels remained full of ammonia,” stated Coleman.

Once the ammonia had dissipated crews returned to work, at which point an altered valve was flipped, leading to the release of more than 1,000 pounds of ammonia into the air.

Usually ammonia systems incorporate multi-turn valves such as globe valves allowing for a measured release, however the tank in question was utilizing a quarter turn ball valve.

Multi-turn valve (Image Credit: CFJC Today)

“The nature of that type of valve is that it is either fully open or fully closed, there is not a lot of metering for in-between. When it was opened by the person working on it, it was fully opened and it discharged a very uncontrolled release of the contents of ammonia in the vessel,” said Coleman.

Quarter turn ball valve (Image Credit: TSBC)

TSBC released three recommendation from their report in the hopes of avoiding a similar tragedy in the future. The most important recommendation was directed at owners and managers of similar facilities.

“To make sure that licensed contractors and qualified people are involved sufficiently in the disassembly work to ensure and validate that ammonia and oil have been removed and that the equipment is safe and ready for other people to work on it,” stated Coleman.

Further investigations into the incident being conducted by the B.C. Coroner and WorkSafe B.C. are still open and ongoing.