The City of Fernie will focus on improving its health and safety programs in the wake of a damning report into the Fernie arena tragedy.
WorkSafeBC found occupational health and safety systems did not mitigate risks to three men who died after being exposed to ammonia at the facility on October 17. 2017.
The agency also determined incident-response measures were not present when Lloyd Smith, Wayne Hornquist and Jason Podloski were performing maintenance on ice-making equipment at the arena, and this was a contributing factor in their deaths.
WorkSafeBC released its incident investigation report into the arena tragedy last Wednesday, August 29.
City of Fernie Chief Administrative Officer Norm McInnis said he and his staff are working through the WorkSafeBC report, as well as the orders given.
The City was found to have violated eight sections of the Workers Compensation Act and Occupational Health and Safety Regulation.
These included failing to conduct regular inspections of the workplace to prevent unsafe working conditions and failing to develop, and implement an exposure control plan for ammonia in the workplace.
WorkSafeBC also identified two violations by Toromont Industries Ltd. (CIMCO Refrigeration) for failing to protect the health and safety of CIMCO workers.
“I think there’s a bit of a disconnect between our health and safety program and this particular incident,” said McInnis when asked for his initial reaction to the report.
“I’m going through the orders now and the full document, and am just trying to reconcile some of our health and safety practices as they pertain to the order, and how they relate to the incident.”
WorkSafeBC’s findings confirmed Technical Safety BC’s report, which stated the gas leak was caused by a small hole within the chiller, which allowed for ammonia to mix with the brine solution. Asked what the City took away from the reports, McInnis said both are very detailed, but very different.
“I think both of them, especially the Technical Safety report, suggests that this was a one-of-a-kind incident,” said McInnis, referring to a comment by Jeff Coleman, director of risk and safety knowledge at Technical Safety B.C.
“The WorkSafeBC report sort of suggests that this should have been part of our hazard assessments, and our health and safety program should have made provisions for this.
“But it just was not seen as a hazard in the industry or industry training until after the accident in Fernie occurred.
“And I think that’s really what I want people to understand,” he continued.
“This was unprecedented. And no, it wasn’t part of our risk assessment because it just was not identified as a risk.”
McInnis says he’s heard questions surrounding why the chiller was put back into service, and says there simply was no recognition of any major risk involved in doing that.
“The advice from CIMCO was to monitor it,” said McInnis.
“As Quinn Newcomb (Interim Vice President of Human Resources, Learning and Engagement) from Technical Safety BC said in the press conference, it’s likely that it was put back into service, and the thought was, at worst case, we have to take it back out of service and we lose the ice.”
McInnis says he understands there will continue to be much discussion surrounding these two reports, and why the chiller was put back into service but, “it just wasn’t a part of anyone’s risk assessment, at that time”.
“It needs to be now, and of course, Technical Safety is putting it into their protocols. It’s part of training protocols now. There’s a ton of learning in both of these reports.”
2. WorkSafeBC report, section 3.2.2 – Incident response measures were not present
In section 3.2.2 by WorkSafeBC, the report states that, “When the stage 2 mechanical failure occurred and released high concentrations of ammonia gas, the Fernie firefighters had already been dismissed, and the automatic alarm systems had been disabled. There was no mechanism in place to alert any party that a serious incident had occurred. Additionally, workers in the room were not wearing adequate personal protective equipment for the exposure levels that they were exposed to.”
The night of the tragedy, McInnis says the emergency response was well executed and done to a very high level.
“The emergency responders stayed there until the plant was shut down, and the ammonia had dissipated,” he said.
McInnis says he believes there was, at that point, no realization by staff present that there was a hazard lurking back in that room.
“WorkSafeBC says that incident response should have stayed there, and going forward, absolutely that’s probably going to change a number of protocols,” said McInnis.
“But that was not the protocol at that time. The emergency response worked as it should, and I believe that there was an understanding that the hazard had been taken care of.”
Section 3.2.2 further states that, “Fernie had not reviewed the emergency procedures or conducted any practice drills for many years prior to the incident”, which meant staff were unfamiliar with procedures when the incident occurred.
McInnis says that although there is no documentation of practices drills being completed, he is confident that they did happen. He admitted that they need to work to improve their communication and documentation, as stated by WorkSafeBC further in their report.
“We have a really robust safety management system, we have a very active joint health and safety committee. We haven’t been documenting the work like we need to,” he said.
3. How and why did the funding for the replacement of the chiller get delayed for years?
In October 2010, seven years prior to the incident, the City of Fernie received a recommendation from their maintenance contractor to replace the curling system brine chiller due to its age.
According to Technical Safety BC’s report, the City initially scheduled funding to replace the curling brine chiller for 2013. This funding was deferred to 2014 and then deleted from further financial planning.
Asked why the funding for the replacement of the chiller was delayed for years, McInnis admitted this is a complex question.
“Obviously there was a recommendation from Startec (Refrigeration) in 2010,” he said.
“In 2013 the facility master plan comes out and says no critical components in the compressor room have any issues. Other work was done, compressors were rebuilt, and the chiller (was) not replaced.
“But again, because a piece of equipment has a life span of 25 years, doesn’t mean it’s used up in 25 years,” he continued.
McInnis says this is just one piece of information considered before a piece of equipment is shipped out and replaced.
From his understanding, McInnis said that the recommendation from Startec in 2010 was simply a ‘heads up’, that the equipment, which was 30 years old, has a life span of 25.
“They continued to send their people into that workspace for five years after that. Again, I just don’t think that the level of understanding of the risk of having ammonia move from that closed loop system anywhere else, was what it needs to be, obviously. We can say that now in hindsight,” said McInnis.
The CAO again referred back to the Technical Safety BC press conference, where Coleman was asked whether they came across any indication of disregard for safety or negligence.
“He said, we don’t test for that, it’s not part of what we do, but there is a standard test, and there was no evidence that that was the case in Fernie,” said McInnis.
Colemen explained at the press conference in July that, “We do have a standard test that we monitor while we are investigating that examines and keeps an eye out for any evidence that is suggestive of either a flagrant disregard for safety or intentional actions that may have contributed to the incident and we did not discover any evidence that suggested an awareness of this hazard (the hole).”
4. What’s next?
McInnis explained that the City of Fernie is required to respond to the orders given by WorkSafeBC within 30 days.
“Both in the WorkSafeBC, and the Technical Safety reports, there is a ton of things in there for us to learn and grow from, and share with other communities,” said McInnis.
“Those are the things that we are, corporately, taking away from all of the stuff that we’ve been through over the last, almost year now.”
In July of 2017, McInnis says the City of Fernie joint health and safety committee completed a self-assessment, and determined at that time, that they wanted to put more time and effort into their health and safety program.
They had started the process towards getting their certificate of recognition, and McInnis says they’re still committed to doing this.
“We’re going to work over the next 18 months and we’re going to get our certificate of recognition, which is not a legislative requirement, but it is a best practice,” he said.
Additionally McInnis says they’re continuing to focus on on structural re-organization, moving asset management up to a more strategic level in the organization. He says he believes that is going to give the City much better information with which to make decisions.
