Officials have released the results of an independent investigation into the death of three men at the Fernie Memorial Arena last fall and the report includes 18 recommendations to help prevent similar incidents from happening.

Allan Hornquist, 59, Lloyd Smith, 52, and Jason Podloski, 46, were doing maintenance at the arena on October 17, 2017 when anhydrous ammonia leaked from the facility's cooling system, killing all three men.

The arena was shut down and 95 people were evacuated from 55 homes near the arena following the incident.

An investigation into the ammonia release was launched by Technical Safety BC, an independent agency that supervises the safe installation and operation of technical systems in the province.

Safety officials released the results of the investigation on Wednesday morning and concluded that ammonia leaked into brine, which is a common secondary coolant, resulting in pressurization in a pipe.

The pipe coupling was compromised and caused the ammonia to be released into an enclosed, mechanical room.

According to Technical Safety BC, the leaking equipment had been returned to operation just one day before the incident happened.

"A clear lack of understanding that the situation presented a hazard. We did not see or discover any evidence that there was an understanding that the condition did present a hazardous potential," said Jeff Coleman, Director of Risk and Safety Knowledge for Technical Safety BC.

Investigators looked at the factors that could have contributed to the leak and also examined the condition of the equipment, inspection reports and the results of system tests.

Three areas were identified as factors that contributed to the incident including;

  1. Refrigeration system equipment failure
  2. Operational decisions that may have added to the incident
  3. Impact of inadequate ventilation and discharge systems

Officials say the investigation revealed that the incident was the result of practices that were common in the industry at the time of the tragedy and say there are two lessons to be learned from the incident.

“The first is, improve arena maintenance programs. Maintenance plans did not consider component wear out or end of service considerations and procedures. All arena maintenance plans should include an understanding and consideration of the increased safety risk that comes with aging equipment. Maintenance programs should incorporate strategies to safely manage equipment as it approaches the wear out phase of its operational service. The second is, improvements are required around hazard awareness of leaking chillers. As an industry we must recognize a leaking chiller is a failed component. We need to implement clear procedures and guidance that safely remove leaking chillers from service once a leak is discovered,” said Coleman.

The report identified 18 recommendations to improve safety including;

  • Maintenance programs for owners, especially for those who operate aging equipment
  • Identification and disclosure of leak hazards
  • Training for owners’ representatives, operators and mechanics
  • Secondary coolant system configuration and construction

The report also outlined a number of regulatory actions that have been taken recently to prevent similar incidents.

A safety order was issued by Technical Safety BC to all ammonia plants in the province, where there is public access, which requires them to test for leaks and shut down systems if necessary.

Officials say all 185 facilities in BC have complied with the order but two rinks were shut down as a result.

The City of Fernie released a statement on Wednesday afternoon saying that the entire industry can learn for the incident…

“As a City we value and are committed to the health and safety of our employees and community members. The ammonia leak, and the subsequent loss of our valued colleagues, is one of the most tragic incidents to happen to our community. We still feel their absence deeply” said City of Fernie Mayor Mary Giuliano in the statement. “Despite working with an approved certification for our system at the time of the incident, today’s report points to opportunities to further improve safety standards for arena refrigeration plants, not only for Fernie but for communities across British Columbia so no one else will need to experience a similar tragedy.”

“The report indicates this is the first known example of an incident like this happening, where the ammonia leaked into a secondary coolant (the brine), leading to a pressure build up and failure of the pipe and then the rapid release of ammonia,” said Giuliano. “There is much the entire industry can learn from this to prevent such an accident in the future, and we will support this learning in whatever way we can.”

In March, officials in the community commissioned a new refrigeration plant for the arena from a Calgary company that uses synthetic refrigerant instead of ammonia.

The technology is being used in other facilities in North America and Europe and the hope is it will be in place in the Fernie arena for the start of the 2018-19 hockey season.

To view the complete report from Technical Safety BC, click HERE.