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.