HVACR installer here. That leak in the tubes is solved by blocking off the tube and not allowing brine into it. As for doing the repair, sometimes the business is just like "get the job done fast, doesn't matter what it takes." Also not having proper PPE is for the refrigeration tech is a fault of the company. You need training in ammonia systems since they are so specialized.
Yeah, I've worked with ammonia based refrigeration systems for a large Canadian food and beverage conglomerate, and you don't work on those sorts of systems without a huge abundance of caution. The company handling the refrigeration system absolutely should've been more aware; you don't get into that business without understanding the risks and dangers (speaking of administration not the technicians).
So quick question in regards to this. The video said they isolated the brine container(?) that has the leak. Would thev decoupling still have happened? I would have assumed if they had a leak they would have drained all the water out of the system so brine wouldn't constantly be leaking into the water.
@@zadinal isolating it means its valved off from the system. As for the coupling breaking, I'm not sure since I mostly do residential but if the pumps kept running, eventually something's going to fail.
@@zadinal The problem would have been the ammonia refrigerant leaking into the brine side of the heat exchanger. Even with the brine side of the exchanger closed off, with the compressors shut down the ammonia would still have in pressure, leaking even more and probably going over the rated pressure for the brine side valves, which would have failed. The best way to avoid any issue would have been to recover the ammonia charge, recovering all the brine from the system and either repair or replace the leaking heat exchanger.
They actually had to evacuate a small area of the town around the Arena but the video fails to mention that it could have been far worse because emergency crews were only called when one of the workers staggered outside and collapsed. If I remember right, the leak wasn’t taken seriously by the repair team and they wanted to get everything restarted so the hockey team could still host a home game later that week.
Silencing the alarm and not wearing any PPE second time round makes no sense to me... If you're expecting some exposure then sure, silence the alarm to save everyone's ears but wear PPE. If you're not expecting any exposure then maybe forgo some of your PPE but have the alarm active as it will let you know if you're at risk with your lack of PPE!!
it sounds more like they tricked the mechanic into working on the system. majority of us (I work in HVAC) would tell them they need to fix the leak before touching it. So they took that man's life without him knowing what he was walking into. (my guess)
100% city’s fault. I’m an electrician by trade and when I was in the field I used to do hot work (electricity on) in Las Vegas because we “couldn’t” stop the machines from making money. I wasn’t worried and didn’t get hurt, but I’m sure in different industries shucking these safety requirements is rather common.
@@willlock3644 it is **Probably** legal as long as the electritian is aware and properly certified to do it, in some cases it really isnt possible to turn of the power, so i would assume that there would be either some cases when it would be allowed (in which case the casino might be doing something shady) OR there are some or all electricians who are certified to work on hot wires
@@willlock3644 if it creates a danger to others by being powered off like fire alarms, or is a major business disruption hot work can be done. Or it was allowed in those cases 4 years ago.
@@willlock3644 if you’re in a failure = boom situation and need to fix the one thing that keeps it from going boom, I doubt OSHA can successfully tell said business to go boom, so there ought to be some special precautions and certifications for hot work and other dangerous tasks that will need doing whether OSHA wants it or not
I worked at a rink that experienced an ammonia leak. I'm very fortunate to have trusted my instincts that day due to the fact that I had no idea what ammonia was or the danger involved with me being in proximity to it. When I was exposed to ammonia, I thought I was hit with tear gas. All I remember was the crippling pain in my chest, difficulty breathing and my eyes burning. Thankfully I was the only person in the building at the time and thankfully, I was able to vent the room and safely wait for the fire department to arrive. Had that happened to me now, I wouldn't have spent 2 seconds inside that building.
I've watched this investigation a few times, and every time I hear " [...] prior to the arrival arrangements were made to put the ammonia alarm in silent mode [...] " my heart sinks.
The ammonia alarm would not have alerted the workers that a pipe union was about to explode showering them with ammonia saturated brine. It seems like a critical error but the ammonia alarm would not have saved their lives.
Trying a 3rd time! Guess I can't link or give search terms to the technical safety BC investigation. CZcams thinks I'm spam 😡 Turns out that chiller was identified as past its end of life in 2010. The chiller was then deferred from replace from 2013 to 2014. Then in 2014, the task to replace the chiller was deleted. Also was found that during the 2017 off season the brine was sampled twice and ammonia was detected in both samples. The city decided to monitor the chiller 🤦♀️ Then during an October 4th meeting, the meeting minutes noted that the chiller system was broken and in need of mandatory replacement... in 2018 Can there be 200% blame assigned to the city?
also they may not have started it up at all if the incompetent earlier workers didn't silence the alarm. Alarms are meant to be the most annoying thing on the planet so that you react to them immediately in a way relevant to the given situation.
The workers who died are the same workers who were there with the fire fighters. The workers started the compressor because the chiller that had the leak was for the curling rink so they split the system and fired up the rink side, it was a safe and proper thing to do. Just some more info that this video left out
It *would* have been the safe thing to do if they didn't completely block off the leaky heat exchanger, isolating it from expansion tanks / pressure relief systems
@@doodlecaboodle9298 Meaning it needs improvement, I was disagreeing with the “it was a safe and proper thing to do”, the outcome alone contradicts this. If you’re saying it’s following safety protocols, then sure, I don’t have the expertise to know either way.
It is really sad for the people completely unaware of the major problem and lost their lives. Sounds like many types of negligence. I mean you had people enter the building with hazmat suits and respirators earlier. So the people in charge knew the problem was serious. They silence the alarm, which I can understand if you take the proper safety steps. Then ask a 3rd party to hire someone(4th party?) to do a basic routine maintenance job, replacing oil, without telling one or both of them anything.
Possibly I am missing something but I could have sworn at one point the workers isolated the heat exchanger involved. Isolating the heat exchanger should have prevented water from entering the ammonia filled exchanger and solved the problem. At that point the workers would consider the machinery "made safe". This is a somewhat reasonable conclusion as normally this is how systems are made safe. Unfortunately it sounds like the water already present in the pipes of the isolated heat exchanger was enough to produce sufficient overpreasure to rupture the system. Very scary as isolating the heat exchanger should have made it safe.
@@xSonicspeedx So, you want him to edit his own comment & correct a misspelling to appease some weird stranger on the internet who can’t understand that typos happen? That’s called entitlement. It’s gross.
@@evilsharkey8954 You are probably correct, but I personally wish people were more willing to call a spade a spade. That said, there is something to be said for not spreading incorrect information that hurts someone's reputation without a genuine basis. In the case of an accident with fatalities or grevious injury though it may be more valuable to explain things fully than it is to avoid any mistaken criticism. I would prefer safety analysis avoid factually conclusory statements and simply qualify everything with a caveat regarding the quality of the evidence. They should present the most likely scenarios and the supporting evidence and leave conclusions that would be potentially harmful to someone's reputation up to the viewer evaluating the evidence. Hiding the identity of a decision-maker makes it very difficult to learn from mistakes in the area of human factors. For example, people get injured because they were pressured by a boss to do something unsafe, and it would be difficult to warn people about that scenario without implicating the boss made a dangerously poor decision.
So the usually safe isolation of the heat exchanger (which would allow for restart) caused a failure when it formed a closed system that had pressure buildup. NEVER BLOCK OFF THE PRESSURE RELIEF
Upon looking back at a 2018 news report on global bc, adding to the blame, the town of Fernie should have replaced the system in 2010, so definitely their fault. This was mishandling at its worst
Reading between the lines here, I think I have this more-or-less correct: The system contained presssure, and presumably had an expected failure mode that would transfer the pressure to adjoining systems. Presumably, the brine overflow tanks were receiving that pressure as it was added to the brine system, and by closing valves, you cut out that pressure relief, creating what was essentially a poison gas bomb from what had been a system failing ‘semi-safe’ - yeah, sure, it was leaking ammonia. Yeah sure, it was blaring an obnoxious alarm to warn of danger. The bit that was releasing gas was supposed to release gas, the bit that was blaring was supposed to blare. Actions taken swept the problem under the rug, but as anyone who has tried keeping their pet lion under a rug, some problems don’t sit quietly underneath rugs no matter how nicely you say ‘stay’.
Obviously, all these reactions to work place disasters are tragic, but this was fairly simple in that there weren't many different variables that could have been the cause. This was one leak that was negligently ignored until it was too late. Yes there was PPE issues and a breakdown in communication, but only one (fairly easy to fix if done regularly) mechanical issue.
from what someone else said in another comment, the city knew about the chillers for years and they were past their servicing date back in 2010. So the city knew about this possible issue in advance...
I worked at a Canning Facility and we had an Ammonia leak for a whole year. They refused to fix it because of how much the downtime would cost. I inhaled Ammonia for a year
As someone who has lived their entire life in Canada (all but 2 years in BC) I'm really not surprised. Those smaller outlier towns are poorly managed and there's a high possibility of a power tripping manager handling tasks that they are not prepared for. They probably got a manual right after starting that they read and then forgot for 15 years.
Ice Hockeyer/Law Student. Got an interesting perspective/note. I'm a law student. I do online classes now because I mean the world is on fire but when I was in person uni I was on the University ice hockey team (I'm British all you had to do to get a spot was show up basically haha). I absolutely am not saying what they did was OK or reasonable but I want to point out if that rink melts, it takes literally days to re ice it. You are talking about the difference between a five minute Zambroni job and a days long project. It is absolutely foreseeable that people would try to preserve the ice. Fault aside, I think it is absolutely a failure of procedure that this outcome was not expected and planned against, because I imagine most people in that position would, if not properly informed like it seems here, turn the machine back on to keep the ice. I'm not an engineer. Idk if some sort of failsafe is possible. But I do think there needed to be more put in place to stop these people from turning it back on because it is absolutely foreseeable that they would in my eyes. Especially if this was during the season. If the team can't get on to the rink for practice because you've "let" the ice melt, you're gonna have a lot of angry people. Again, not saying it was the right decision but it goes to your asking about pressure on the workers from bosses etc.
@@dynad00d15 I would imagine the families of the deceased workers would welcome an explanation that shifts blame away from said workers, so I'm not quite sure what your point is?
I owned a couple of gas Wells for several years if the animation was accurate they were using a compression style coupling which has been outlawed in the gas industry in most cases for a number of years due to the fact they blow off they come loose occasionally leak the overpressure in the brine system should have been accounted for in the engineering of the system to my eye it would seem that it was an old system that was jerry-rigged together that coupling was a patch somebody put in and number of years ago they're also should have been a pressure release valve such as on a steam boiler or even a hot water tank which would have released the pressure in a safe controlled manner it appears that there were multiple failures that led to this incidence as far as PPE goes safety glasses and work gloves would not have helped you in this situation with the ammonia leak compartmentalized there would be very little reason to be wearing a breathing apparatus I would also think that there should be pressure gauges in both ammonia and brine systems so that the pressure could be verified but I suspect it was an old system that may have not had modern safety features
HEY! I LIVE IN BC!!!! I was nearby when that ammonia rink leaked! They had to evacuate a HUGE area! I don’t know if it was necessary or not but there was a huge panic and lots of confusion as to what was happening when the fire trucks, cops were going down all streets telling everyone to leave the area, saying a possible imminent explosion/poisonous gas leak was occurring but they didn’t know yet. Anyway the city of Fernie sued the refrigeration company CIMCO Refrigeration for $650k CAD in 2020. Still in the courts. I never heard of the families suing or anything. Work Safe BC here generally covers costs related to workplace accidents and deaths. The pipe would have cost $57k to fix.
That's the stupidest thing. A system was broken and they didn't try to figure out where and what it's going to take to fix it? Fix it before you try to get it running again. Very sad all those folks had family.
This is upsetting. I use ammonia in my refining lab, and while it's on a very small scale, I still use PPE and ventilation along with gas monitoring equipment. The fact that professional level, especially city workers were this negligent, makes me so mad. I mean at least hang a sign of you're too stupid to communicate an issue with dangerous equipment.
8:51 "Who they brought on the very next morning..." That wasn't even the next morning! That was the SAME morning! That incident occurred a mere 4.5 hours after the Firefighters just left! Those (several unflattering adjectives) couldn't even be bothered to waste any time before royally screwing themselves because they wanted ice. They essentially stuck their head in a beehive, got stung on the nose and pulled out, felt their head and went "Aww shoot! I left my hat in there!" and stuck their head right back into that beehive. Some people...
I think I remember hearing about this story at the time. It's morbidly interesting to learn what actually happened beyond the headlines about a tragedy. I think some important context that @AttorneyTom is missing is the perceived importance of this kind of facility to a small Canadian town (~5000 people) like this. It makes it much easier see why the workers could be pressured to save the ice. It's not a justification but it makes me wonder what the thought process of the person making that decision was
See there's a new attorney Tom video click on it immediately only to realize it's a re-upload that I've already watched. Sadness! Oh well attorney Tom's content is worthy of my time so I'll watch it again.
The way the last segment was worded, it sounds like the 3 who died to turn it back on just chose not to wear ppe and detectors, but given the context that the machinery had already been put back together and was ordered to restart it's possible that it was implied to or told them that the machine was fixed and everything was safe
As a PSM coordinator for an ammonia refrigeration system, I still have so many questions about this incident. Just to clarify...restarting the system is not what caused the final leak. When they 1st valved things off to stop the leak out of the tanks, all they did was trap it inside the system allowing the pressure to build at that coupling. But why then call out a contractor to replace the contaminated oil before figuring out how the brine got in the oil in the first place? Fault is definitely on the owner/operator of the facility for not properly identifying the leak inside the chiller.
It works that way in a lot of corporations, too… until they get their asses sued to the Stone Age for gross negligence, and their reputation is fouled for decades.
Kind of a guess but the diagram suggested the ammonia alarm goes off at 35ppm and the firefighters got the concentration down to 50ppm. So it's possible the alarm was silenced because it was still going the whole time.
I’m still one of the only people in my family who’s ever ice skated (I live in Australia), so I can relate to Tom on that being something to brag about.
They did season start up 6am the day before, and the call was to restart the compressors to save the ice? What ice? The pads take 12+ hours to get cold enough to start making ice depending how big your compressors are.
TOM PLEASE consider making a video analysis to a CZcams channel called DissociaDID's new video! I think it would make an interesting video where you could discuss the legality of copyright, harrassment, and abuse of the legal system in bad faith as a revenge tactic. The channel is owned by a system who has Dissociative Identity Disorder, and this occurence caused them extreme stress. They show a lot of receipts that I think could be easily looked at in an objective legal lens.
Huh. I had a coworker at the pool I worked at almost die from something g similar back in 2009, they had to drag him out of the workroom and ventilate him
Or there were only a few trained ppl at the site. I know my old boss was the only one with real ammonia training allowed to work on the systems. Basically if u can see a cloud of ammonia it will kill u nearly instantly.
So whoever was responsible for not fixing the leak shouldn’t have any fault. The entire situation was handled in a proper and safe manner and ready to be repaired. Whatever factors were involved in the decision to restart without a proper repair are where 100 percent of the fault lies.
While disabling the alarm was a really stupid thing to do, I don't know that it would have made a difference. If it was still going off, the new workers probably would have put PPE on, but it's hard to know if the building was ventilated to non-alarm levels. Also don't know what the handoff looked like, that might shift the blame to the person that took over. So I'd put either 60% or 0% on whoever disabled the alarm. Between 10% and 50% on the new workers that should have been wearing PPE, depending on what they were told about the situation. Some blame for whoever was responsible for regular maintenance, if they didn't find the leak or didn't recommend whatever inspection measures were necessary to find such a leak. If they did document such a leak, this blame shifts to whoever decided not to fix it. Some blame on whoever designed the system if there was no pressure relief mechanism in the isolated section. Possibly some blame on whoever manufactured the failed coupling, if it failed below its rated operating pressure.
I remember watching that video a while back! Kinda crazy how many views it has, not a typical CZcams video, but it is fascinating. I think they have a few other interesting videos.
As an HVACR tech for 12 years, i can "safely" say that safety is not a concern lol. Employers want the work done. If you can't do it, they'll hire someone else to take your place.
The Monte Carlo Fallacy… the belief that because certain events have taken place in the past, certain events will take place in the future. It’s a scary thing that happens to humans… it’s what causes skydivers to forget to open their chutes because they are so comfortable falling or soldiers being so comfortable in battle they start taking greater risks… I think the same thing happened here, these workers were so comfortable in this environment they didn’t think anything bad would happen.
I wanna know why there was no pressure relief apparatus installed on the system that contained two chemicals that can cause a dangerous increase in pressure.
Idfk how u could know if a pipe needs to be repaired and if they shouldn’t mix then why do they share the same pipe? To prevent stuff like this shouldn’t they keep them separate? If they mix then how do you drain it before it gets worse?
I KNOW I LOOK TIRED THIS VIDEO WAS FILMED AT LIKE 1AM. DON'T @ ME
@
You look fine you're too self conscious
I wasn't gonna but now....😒
Naaaah you looking fine 💅
Bahahahahahahhaha
You don't look tired at all. You seemed to be your usual scruffy self.
HVACR installer here. That leak in the tubes is solved by blocking off the tube and not allowing brine into it.
As for doing the repair, sometimes the business is just like "get the job done fast, doesn't matter what it takes."
Also not having proper PPE is for the refrigeration tech is a fault of the company. You need training in ammonia systems since they are so specialized.
Yeah, I've worked with ammonia based refrigeration systems for a large Canadian food and beverage conglomerate, and you don't work on those sorts of systems without a huge abundance of caution. The company handling the refrigeration system absolutely should've been more aware; you don't get into that business without understanding the risks and dangers (speaking of administration not the technicians).
So quick question in regards to this. The video said they isolated the brine container(?) that has the leak. Would thev decoupling still have happened? I would have assumed if they had a leak they would have drained all the water out of the system so brine wouldn't constantly be leaking into the water.
@@zadinal isolating it means its valved off from the system. As for the coupling breaking, I'm not sure since I mostly do residential but if the pumps kept running, eventually something's going to fail.
@@lillian6023 the problem is that isolating the brine side of the heat exchanger isolated the pressure relief and created a bomb
@@zadinal The problem would have been the ammonia refrigerant leaking into the brine side of the heat exchanger.
Even with the brine side of the exchanger closed off, with the compressors shut down the ammonia would still have in pressure, leaking even more and probably going over the rated pressure for the brine side valves, which would have failed.
The best way to avoid any issue would have been to recover the ammonia charge, recovering all the brine from the system and either repair or replace the leaking heat exchanger.
They actually had to evacuate a small area of the town around the Arena but the video fails to mention that it could have been far worse because emergency crews were only called when one of the workers staggered outside and collapsed.
If I remember right, the leak wasn’t taken seriously by the repair team and they wanted to get everything restarted so the hockey team could still host a home game later that week.
It is Canada...🙄
Silencing the alarm and not wearing any PPE second time round makes no sense to me... If you're expecting some exposure then sure, silence the alarm to save everyone's ears but wear PPE. If you're not expecting any exposure then maybe forgo some of your PPE but have the alarm active as it will let you know if you're at risk with your lack of PPE!!
it sounds more like they tricked the mechanic into working on the system.
majority of us (I work in HVAC) would tell them they need to fix the leak before touching it. So they took that man's life without him knowing what he was walking into. (my guess)
@@linuxd I thought so too. They silenced the alarm for the mechanic, but then he couldn't wear ppe either
100% city’s fault.
I’m an electrician by trade and when I was in the field I used to do hot work (electricity on) in Las Vegas because we “couldn’t” stop the machines from making money. I wasn’t worried and didn’t get hurt, but I’m sure in different industries shucking these safety requirements is rather common.
What does osha say about “hot work” ?
@@willlock3644 it is **Probably** legal as long as the electritian is aware and properly certified to do it, in some cases it really isnt possible to turn of the power, so i would assume that there would be either some cases when it would be allowed (in which case the casino might be doing something shady) OR there are some or all electricians who are certified to work on hot wires
@@willlock3644 if it creates a danger to others by being powered off like fire alarms, or is a major business disruption hot work can be done. Or it was allowed in those cases 4 years ago.
Here's hoping you wear a barehand suit while doing hot work... yikes.
@@willlock3644 if you’re in a failure = boom situation and need to fix the one thing that keeps it from going boom, I doubt OSHA can successfully tell said business to go boom, so there ought to be some special precautions and certifications for hot work and other dangerous tasks that will need doing whether OSHA wants it or not
Im a former military EMT.
Dying from AMMONIA EXPOSURE is one of THEE MOST painful ways to die. Its like inhaling or drinking MOLTEN HOT LAVA. 🥺😰😭
Want some bleach to ease the pain 😂
I was afraid of that.
Ammonia stinks. Litteraly. That's one of the saddest way to go honestly.
I was a pipewelder for a refrigeration contractor for 10 years and I agree 100 percent
I worked at a rink that experienced an ammonia leak. I'm very fortunate to have trusted my instincts that day due to the fact that I had no idea what ammonia was or the danger involved with me being in proximity to it. When I was exposed to ammonia, I thought I was hit with tear gas. All I remember was the crippling pain in my chest, difficulty breathing and my eyes burning. Thankfully I was the only person in the building at the time and thankfully, I was able to vent the room and safely wait for the fire department to arrive. Had that happened to me now, I wouldn't have spent 2 seconds inside that building.
I've watched this investigation a few times, and every time I hear " [...] prior to the arrival arrangements were made to put the ammonia alarm in silent mode [...] " my heart sinks.
Ikr? It's like watching the parent figure smash the princess's thing causing them to storm off into the inciting incident of the movie.
The ammonia alarm would not have alerted the workers that a pipe union was about to explode showering them with ammonia saturated brine. It seems like a critical error but the ammonia alarm would not have saved their lives.
Trying a 3rd time! Guess I can't link or give search terms to the technical safety BC investigation. CZcams thinks I'm spam 😡
Turns out that chiller was identified as past its end of life in 2010. The chiller was then deferred from replace from 2013 to 2014. Then in 2014, the task to replace the chiller was deleted.
Also was found that during the 2017 off season the brine was sampled twice and ammonia was detected in both samples. The city decided to monitor the chiller 🤦♀️
Then during an October 4th meeting, the meeting minutes noted that the chiller system was broken and in need of mandatory replacement... in 2018
Can there be 200% blame assigned to the city?
I second the motion for 200% blame on the city.
Third
This is just very sad to see. All three of those deaths could have been prevented if they just had proper communication from the other workers
also they may not have started it up at all if the incompetent earlier workers didn't silence the alarm. Alarms are meant to be the most annoying thing on the planet so that you react to them immediately in a way relevant to the given situation.
The workers who died are the same workers who were there with the fire fighters. The workers started the compressor because the chiller that had the leak was for the curling rink so they split the system and fired up the rink side, it was a safe and proper thing to do. Just some more info that this video left out
The outcome disagrees.
@@lupita3689 FR 😂
It *would* have been the safe thing to do if they didn't completely block off the leaky heat exchanger, isolating it from expansion tanks / pressure relief systems
@@lupita3689 safety protocols Don't always work
@@doodlecaboodle9298 Meaning it needs improvement, I was disagreeing with the “it was a safe and proper thing to do”, the outcome alone contradicts this.
If you’re saying it’s following safety protocols, then sure, I don’t have the expertise to know either way.
It is really sad for the people completely unaware of the major problem and lost their lives. Sounds like many types of negligence. I mean you had people enter the building with hazmat suits and respirators earlier. So the people in charge knew the problem was serious. They silence the alarm, which I can understand if you take the proper safety steps. Then ask a 3rd party to hire someone(4th party?) to do a basic routine maintenance job, replacing oil, without telling one or both of them anything.
Possibly I am missing something but I could have sworn at one point the workers isolated the heat exchanger involved. Isolating the heat exchanger should have prevented water from entering the ammonia filled exchanger and solved the problem. At that point the workers would consider the machinery "made safe". This is a somewhat reasonable conclusion as normally this is how systems are made safe. Unfortunately it sounds like the water already present in the pipes of the isolated heat exchanger was enough to produce sufficient overpreasure to rupture the system. Very scary as isolating the heat exchanger should have made it safe.
I was with you until you spelled pressure wrong.
@@justinlewis1657 they're literally right next to each other, the A and S
@@ethanclupper7034 That's what the edit button is for.
@@xSonicspeedx
So, you want him to edit his own comment & correct a misspelling to appease some weird stranger on the internet who can’t understand that typos happen? That’s called entitlement. It’s gross.
@@mayaw.4013 for sure
"It was decided [...] to try to save the arena's ice." It was decided?! By who? They just left that part vague on purpose I believe.
They left it open so they wouldn’t have to deal with any legal issues.
@@evilsharkey8954 You are probably correct, but I personally wish people were more willing to call a spade a spade. That said, there is something to be said for not spreading incorrect information that hurts someone's reputation without a genuine basis. In the case of an accident with fatalities or grevious injury though it may be more valuable to explain things fully than it is to avoid any mistaken criticism. I would prefer safety analysis avoid factually conclusory statements and simply qualify everything with a caveat regarding the quality of the evidence. They should present the most likely scenarios and the supporting evidence and leave conclusions that would be potentially harmful to someone's reputation up to the viewer evaluating the evidence. Hiding the identity of a decision-maker makes it very difficult to learn from mistakes in the area of human factors. For example, people get injured because they were pressured by a boss to do something unsafe, and it would be difficult to warn people about that scenario without implicating the boss made a dangerously poor decision.
So the usually safe isolation of the heat exchanger (which would allow for restart) caused a failure when it formed a closed system that had pressure buildup.
NEVER BLOCK OFF THE PRESSURE RELIEF
If you've had a whiff of ammonia. You know how horrible death by over exposure to it would be.
Apparently, it’s even worse than that.
Upon looking back at a 2018 news report on global bc, adding to the blame, the town of Fernie should have replaced the system in 2010, so definitely their fault. This was mishandling at its worst
At 8:27 Tom looks genuinely sad/disappointed and disheartened with the accident.
He’s seen what this type of accident does to victims and their families.
Reading between the lines here, I think I have this more-or-less correct: The system contained presssure, and presumably had an expected failure mode that would transfer the pressure to adjoining systems. Presumably, the brine overflow tanks were receiving that pressure as it was added to the brine system, and by closing valves, you cut out that pressure relief, creating what was essentially a poison gas bomb from what had been a system failing ‘semi-safe’ - yeah, sure, it was leaking ammonia. Yeah sure, it was blaring an obnoxious alarm to warn of danger. The bit that was releasing gas was supposed to release gas, the bit that was blaring was supposed to blare. Actions taken swept the problem under the rug, but as anyone who has tried keeping their pet lion under a rug, some problems don’t sit quietly underneath rugs no matter how nicely you say ‘stay’.
Obviously, all these reactions to work place disasters are tragic, but this was fairly simple in that there weren't many different variables that could have been the cause. This was one leak that was negligently ignored until it was too late. Yes there was PPE issues and a breakdown in communication, but only one (fairly easy to fix if done regularly) mechanical issue.
from what someone else said in another comment, the city knew about the chillers for years and they were past their servicing date back in 2010. So the city knew about this possible issue in advance...
I worked at a Canning Facility and we had an Ammonia leak for a whole year. They refused to fix it because of how much the downtime would cost. I inhaled Ammonia for a year
Sue! Sue everybody! Call Tom!
As someone who has lived their entire life in Canada (all but 2 years in BC) I'm really not surprised. Those smaller outlier towns are poorly managed and there's a high possibility of a power tripping manager handling tasks that they are not prepared for. They probably got a manual right after starting that they read and then forgot for 15 years.
Honestly, that's how most publicly funded rinks operate in North America. Exactly what you described
That ending...that was heartbreaking.
This stinks and I don’t mean the ammonia. Thanks Curler Tom!
Ice Hockeyer/Law Student. Got an interesting perspective/note.
I'm a law student. I do online classes now because I mean the world is on fire but when I was in person uni I was on the University ice hockey team (I'm British all you had to do to get a spot was show up basically haha).
I absolutely am not saying what they did was OK or reasonable but I want to point out if that rink melts, it takes literally days to re ice it. You are talking about the difference between a five minute Zambroni job and a days long project. It is absolutely foreseeable that people would try to preserve the ice. Fault aside, I think it is absolutely a failure of procedure that this outcome was not expected and planned against, because I imagine most people in that position would, if not properly informed like it seems here, turn the machine back on to keep the ice. I'm not an engineer. Idk if some sort of failsafe is possible. But I do think there needed to be more put in place to stop these people from turning it back on because it is absolutely foreseeable that they would in my eyes.
Especially if this was during the season. If the team can't get on to the rink for practice because you've "let" the ice melt, you're gonna have a lot of angry people. Again, not saying it was the right decision but it goes to your asking about pressure on the workers from bosses etc.
Now lets try this argument with the families of the deceased workers...
@@dynad00d15 I would imagine the families of the deceased workers would welcome an explanation that shifts blame away from said workers, so I'm not quite sure what your point is?
I wonder if the fire department had an obligation to lock out the equipment until inspected. Seems like a reasonable measure to me.
Tom's facial expressions are the best thing about these videos.
His eyes say exactly what we were all feeling when the narrator said “the ammonia levels were not survivable”
I owned a couple of gas Wells for several years if the animation was accurate they were using a compression style coupling which has been outlawed in the gas industry in most cases for a number of years due to the fact they blow off they come loose occasionally leak the overpressure in the brine system should have been accounted for in the engineering of the system to my eye it would seem that it was an old system that was jerry-rigged together that coupling was a patch somebody put in and number of years ago they're also should have been a pressure release valve such as on a steam boiler or even a hot water tank which would have released the pressure in a safe controlled manner it appears that there were multiple failures that led to this incidence as far as PPE goes safety glasses and work gloves would not have helped you in this situation with the ammonia leak compartmentalized there would be very little reason to be wearing a breathing apparatus I would also think that there should be pressure gauges in both ammonia and brine systems so that the pressure could be verified but I suspect it was an old system that may have not had modern safety features
HEY! I LIVE IN BC!!!! I was nearby when that ammonia rink leaked! They had to evacuate a HUGE area! I don’t know if it was necessary or not but there was a huge panic and lots of confusion as to what was happening when the fire trucks, cops were going down all streets telling everyone to leave the area, saying a possible imminent explosion/poisonous gas leak was occurring but they didn’t know yet.
Anyway the city of Fernie sued the refrigeration company CIMCO Refrigeration for $650k CAD in 2020. Still in the courts. I never heard of the families suing or anything. Work Safe BC here generally covers costs related to workplace accidents and deaths. The pipe would have cost $57k to fix.
Comment to place this a bit higher in the comments
Hindsight is 20/20 but a blind man could see this coming. This seems to be beyond wrongful death...
Notification squad going strong
aye aye
MVPs right here
Yes please
Simps
That's the stupidest thing. A system was broken and they didn't try to figure out where and what it's going to take to fix it? Fix it before you try to get it running again.
Very sad all those folks had family.
Your immediate thought when your attorney pronounces “plethora” like that…. “Well, I’m fucked.”
This is upsetting. I use ammonia in my refining lab, and while it's on a very small scale, I still use PPE and ventilation along with gas monitoring equipment. The fact that professional level, especially city workers were this negligent, makes me so mad. I mean at least hang a sign of you're too stupid to communicate an issue with dangerous equipment.
Anyone directly involved in not reporting nor fixing the issue are 100% responsible for those 3 deaths. Negligence at best.
8:51 "Who they brought on the very next morning..." That wasn't even the next morning! That was the SAME morning! That incident occurred a mere 4.5 hours after the Firefighters just left! Those (several unflattering adjectives) couldn't even be bothered to waste any time before royally screwing themselves because they wanted ice. They essentially stuck their head in a beehive, got stung on the nose and pulled out, felt their head and went "Aww shoot! I left my hat in there!" and stuck their head right back into that beehive. Some people...
I think I remember hearing about this story at the time. It's morbidly interesting to learn what actually happened beyond the headlines about a tragedy. I think some important context that @AttorneyTom is missing is the perceived importance of this kind of facility to a small Canadian town (~5000 people) like this. It makes it much easier see why the workers could be pressured to save the ice. It's not a justification but it makes me wonder what the thought process of the person making that decision was
See there's a new attorney Tom video click on it immediately only to realize it's a re-upload that I've already watched. Sadness! Oh well attorney Tom's content is worthy of my time so I'll watch it again.
this is new though.
@@TheRumpletiltskin I have definitely already seen it. It must have gotten taken down possibly before you saw the original.
I agree, 100% the city. I love these. Teasing this stuff out is fun.
I Insulate chillers. When they schedule to open one and clean the pipes, that's pretty much all they do. They run long pipe cleaners through it.
The way the last segment was worded, it sounds like the 3 who died to turn it back on just chose not to wear ppe and detectors, but given the context that the machinery had already been put back together and was ordered to restart it's possible that it was implied to or told them that the machine was fixed and everything was safe
I'm from Michigan and have Never Curled, so you got me there @AttorneyTom
There was a large tournament happening at the time, it's big money for small towns. City probably wanted to save ice for profits...
Can you react to more job safety Videos preferably from the USCSB please.
According to an article at the time the leak ended up leading to evacuation of homes, buisnesses and a retirement home by the arena
As a PSM coordinator for an ammonia refrigeration system, I still have so many questions about this incident. Just to clarify...restarting the system is not what caused the final leak. When they 1st valved things off to stop the leak out of the tanks, all they did was trap it inside the system allowing the pressure to build at that coupling. But why then call out a contractor to replace the contaminated oil before figuring out how the brine got in the oil in the first place? Fault is definitely on the owner/operator of the facility for not properly identifying the leak inside the chiller.
They did not have appropriate safety gear, and they were not wearing monitors. Big fat knowledge hammer
I'm from British Columbia Canada and I remember when this happened
You should check out some chemical safety board (CSB) videos, there is one on a propane tank explosion that you might find interesting
You know damn well that their boss told them to get it started again without fixing it because that’s how that bullshit works in the government
It works that way in a lot of corporations, too… until they get their asses sued to the Stone Age for gross negligence, and their reputation is fouled for decades.
That look Tom gives at 7:18
Classic
If you sue the government They have a cap on the damages you can receive. That's cap
Hello Law Dude
Kind of a guess but the diagram suggested the ammonia alarm goes off at 35ppm and the firefighters got the concentration down to 50ppm. So it's possible the alarm was silenced because it was still going the whole time.
I’m still one of the only people in my family who’s ever ice skated (I live in Australia), so I can relate to Tom on that being something to brag about.
I have never curled. I'm Swedish.
@@CainXVII Completely forgot about this comment. I was just like “Okay? You’re telling me this why???” Haha.
I am suprised a Texan has curled tbh lol
The city worker valves off the “expansion tank” the safety device that protects the pipes from extreme pressures.
I wondered when we were going to crossover from USCSB videos to WorkSafeBC.
They did season start up 6am the day before, and the call was to restart the compressors to save the ice? What ice? The pads take 12+ hours to get cold enough to start making ice depending how big your compressors are.
TOM PLEASE consider making a video analysis to a CZcams channel called DissociaDID's new video! I think it would make an interesting video where you could discuss the legality of copyright, harrassment, and abuse of the legal system in bad faith as a revenge tactic. The channel is owned by a system who has Dissociative Identity Disorder, and this occurence caused them extreme stress. They show a lot of receipts that I think could be easily looked at in an objective legal lens.
Guess you could say those workers got iced
Oof
as a technician who works on this stuff I would be furious if someone didn't tell me about a life level alarm like that
You should do a legal analysis of the movie “Sing”. Everything that happens in it is illegal.
Huh. I had a coworker at the pool I worked at almost die from something g similar back in 2009, they had to drag him out of the workroom and ventilate him
Won't somebody PLEASE think of the ice!
It is legitimately amazing that you have curled.
With ammonia I would think it's an independent third party.
Or there were only a few trained ppl at the site. I know my old boss was the only one with real ammonia training allowed to work on the systems. Basically if u can see a cloud of ammonia it will kill u nearly instantly.
Oh wow, didn't expect this here, almost forgot this story. It was held up as an example years ago when it was still fresh
Government not fixing underlying problems?! No!
I love this video, shared it with a city which just built a rink.
The original home refrigerators used the same system and were prone to ammonia leaks causing the same problems.
So whoever was responsible for not fixing the leak shouldn’t have any fault. The entire situation was handled in a proper and safe manner and ready to be repaired. Whatever factors were involved in the decision to restart without a proper repair are where 100 percent of the fault lies.
It makes no sense that nobody thought to address the ammonia. I mean why do people think that alarm was on?
" .... who accidentally became a youtuber, he's TIRED TOM. "
I bet last winter there were plenty of people curling in Texas.
I’m gonna just have to default to those Southpark boys and go with a blanket, “blame Canada.”
PANR has tuned in.
While disabling the alarm was a really stupid thing to do, I don't know that it would have made a difference. If it was still going off, the new workers probably would have put PPE on, but it's hard to know if the building was ventilated to non-alarm levels. Also don't know what the handoff looked like, that might shift the blame to the person that took over.
So I'd put either 60% or 0% on whoever disabled the alarm.
Between 10% and 50% on the new workers that should have been wearing PPE, depending on what they were told about the situation.
Some blame for whoever was responsible for regular maintenance, if they didn't find the leak or didn't recommend whatever inspection measures were necessary to find such a leak. If they did document such a leak, this blame shifts to whoever decided not to fix it.
Some blame on whoever designed the system if there was no pressure relief mechanism in the isolated section.
Possibly some blame on whoever manufactured the failed coupling, if it failed below its rated operating pressure.
i love your workplace and industrial accident videos
I remember watching that video a while back! Kinda crazy how many views it has, not a typical CZcams video, but it is fascinating. I think they have a few other interesting videos.
All dead because they tried to save some stupid ice!
As an HVACR tech for 12 years, i can "safely" say that safety is not a concern lol. Employers want the work done. If you can't do it, they'll hire someone else to take your place.
AttorneyTom on ice, when?
Not just ice. It is a hockey rink in Canada
The Monte Carlo Fallacy… the belief that because certain events have taken place in the past, certain events will take place in the future. It’s a scary thing that happens to humans… it’s what causes skydivers to forget to open their chutes because they are so comfortable falling or soldiers being so comfortable in battle they start taking greater risks… I think the same thing happened here, these workers were so comfortable in this environment they didn’t think anything bad would happen.
You’re not the “law dude”, you are “the one and only law dude”
WorkSafeBC videos rock
important alarms such as the ammonia alarm should not even have a silent mode, i dont know what lunatic thought that was even remotely a good idea.
how can you even work on an ammonia system without a gas alarm and carrying PPE
Bruh why are there so many things that can go wrong in life
Not sure how much the alarm mattered here. Levels may have been fine at the time and gone immediately lethal when the pipe burst.
I wanna know why there was no pressure relief apparatus installed on the system that contained two chemicals that can cause a dangerous increase in pressure.
There was. That’s what they shut off in the beginning.
Curling in Texas, that sounds like a country song. 👍
Therapy Gecko makes another appearance! ... Great content as always Tom!
It gets worse, that would have been the most painful 3 minutes of their life too
i guess LOTO of the affected system until validated safe didn't even occur to them
I was an Electrician in the navy. After that short experience, i'll never work for the government again. Rather be homeless.
Well, in the military, you’re “government property”.
Can’t wait to get into tort law next semester.
Explosion or Exposure?
Idfk how u could know if a pipe needs to be repaired and if they shouldn’t mix then why do they share the same pipe? To prevent stuff like this shouldn’t they keep them separate? If they mix then how do you drain it before it gets worse?
I work in production, and I can relate to this video