Canadian refrigeration safety organization Technical Safety BC released an investigation report into the fatal ammonia release at Fernie Memorial Arena. The Vancouver-based group, which oversees the safe installation and operation of technical systems and equipment, also issued 18 recommendations to further improve safety in ice-rink refrigeration systems.

The incident at Fernie Memorial Arena on October 17, 2017, is believed to be the first of its kind, says Technical Safety BC. During the incident, ammonia leaking into a secondary coolant — in this case, brine — led to pressurization in a pipe that resulted in the pipe coupling separation and a rapid release of ammonia into an enclosed room. It resulted in three fatalities as well as the evacuation of 95 residents from 55 nearby homes.

The investigation explored pre- and post-incident factors that may have contributed to the ammonia leak at Fernie, including the equipment used and the condition, inspection reports and the results of systems testing. The team also examined relevant organizational and operational decisions that may have contributed to the incident, and it inspected and tested the alarm, ventilation and discharge systems.

The investigation identified three areas where evidence indicates contributing factors leading to the incident:

  • Failure of refrigeration system equipment.
  • Operational decisions that contributed to the incident.
  • Impact of inadequate ventilation and discharge systems following the incident.

Among the 18 recommendations Technical Safety BC issued to improve safety in ice-rink refrigeration systems in British Columbia were:

  • Owner maintenance programs, especially in relation to aging equipment.
  • Identification of leak hazards and professional disclosure of such hazards.
  • Training of owners’ representatives, operators and mechanics.
  • Secondary coolant system configuration and construction.

Technical Safety plans to work with stakeholders and the Canadian Standards Association to advance their recommendations.

Though ice-rink refrigeration systems are not used for industrial process cooling, they are often similar scale and operation. The safe application of ammonia is subject to detailed regulations in Canada and the United States. In a joint statement, the International Institute of Ammonia Refrigeration (IIAR), International Association of Refrigerated Warehouses (IARW), Ammonia Safety Training Institute (ASTI) and the Refrigerating Engineers and Technicians Association (RETA) noted that “extensive safety standards for ammonia are independently certified by ANSI and generally accepted by industry, regulatory and code agencies across North America.”

“Safety should be a consideration with any refrigeration system. Inherent dangers must be considered with alternate refrigerants such as Freons, synthetic blends and CO2 refrigerants. These refrigerants may not be considered as toxic chemicals but do present many other health risks for operators, potential flammability risks, global warming and higher operating pressures. When considering any refrigerant, care must be taken to ensure that proper safety standards are applied in the system design and appropriate operating and maintenance practices are followed to ensure worker safety and environmental issues are considered,” said the organizations in a joint statement.

To learn more about North American ammonia refrigeration safety standards, visit To read the investigation report and recommendations from Technical Safety BC, visit