On May 26, 2022, a crew was in the process of cutting up and disassembling two ammonia refrigeration systems (referred to as P24 and P34 in this report) at an ice distribution facility located in the Mount Paul Industrial Park located in Kamloops, British Columbia. Those present understood that ammonia had been previously removed from both systems. During the removal of a section of the P34 system containing the receiver and compressor, it was identified that a valve handle protruded past the frame and could cause issues with the rigging process.
Options to deal with the protruding part, such as turning it, were being discussed, and one of the individuals turned the valve handle, resulting in a large release of ammonia, between 1,345 lbs and 1,600 lbs. The individual who turned the handle was sprayed by the ammonia and moved further into the building. The remaining members of the crew evacuated through a nearby open bay door. The individual who opened the valve was extracted from the building and pronounced dead following the incident. In addition to the fatality, there were multiple ammonia exposures, a local evacuation, an extended business shutdown, and an environmental response to the release.
The refrigeration unit had been shut down in 2015 but the ammonia wasn’t removed and, over the years, miscommunication, staffing changes, and then the failure to use a licensed refrigeration contractor to check for ammonia all contributed to the unexpected release.
Root Cause: