I know nobody asked but when i was little, i went to my dads work a lot and stayed in the basement near some alarms, those fucking things didnt shut up for some reason, I might have tinnitus because of it
I hear that, but it would have been going off continuously anyway, negating it's usefulness as the staff was clearly OK with bearing threshold levels...thats common since many alarm systems are set below necessary thresholds-some ridiculously so, I assume for liability reasons (maybe not this one, but people judge by overall experience). I think the real problem here was the city worker's lack of comprehension of the system.....overconfidence in the engineering, lack of understanding of the chemistry involved, etc..
Eiserntors Phantom of the Opera After the firefighters left, the amonia levels never went under the alarm thershold. What difference would it make if the alarm was beeping the whole time?
Since the alarm triggered at 35ppm but room concentration only ever dropped to 50ppm after the fire department arrived (which they found to be workable) the alarm would have just went ignored even if they had not shut it off.
I agree. He has erased all trace of judgy from his delivery. In general, I find that family and friends who chastise me, that judgy tone is always there. Like nails on a blackboard.
Wow. Props to the editor who decided to play the alarm until "silent mode" and then cut them off. Really effective and emotionally striking, especially in a video with an otherwise detached tone.
This happened to my grandfather, the old Chicago Stadium had an ice rink in its basement and he and another worker were using jackhammers to break up the floor of the rink. The ammonia was supposed to have been drained, but wasn't and when they broke through the pipeline, both were overcome. My grandfather survived, but spent a year in hospital, but the other worker died.
because sometimes you can make an area safe while you make repairs but the alarm still sounds until the leak s repaired. the fire department should be the only ones with access to the silence button.
So that you can fix the problem without it blaring at you, the idea being that you only silence the alarm when you actually have a plan to fix the problem.
One reason would be if it's a false alarm because of wiring issues or testing. or if your already aware and working on the issue not much point in keeping the loud ass thing on. they however did it in the worst case possible. they should have at least been monitoring the pressure and should have had personal detection devices they also probably should have worn their PPE and had a crew of fire department outside to keep in touch with them which is what you're supposed to do if you are entering any environments that possible contain hazardous gasses.
ceased* They weren't in danger. They're already dead, and the danger was already known b/c of the alarm. There was no risk here. This was due to gross negligence.
Thats corporate scumbags for you. Dont care about nothing but money. And it was costing them money having the refrigeration system shutdown. And would have cost them more to replace the ice
..same with most industries.. All of this happened within a short time span.. Should have taken every step as if it were leading to the edge of a cliff.. why the hel did they not monitor the atmosphere the entire time?!
I have some colleagues who responded to the tragedy. What isn't mentioned is that this was this heat exchanger was flagged for replacement, and budgeted for by the City back in 2012. However, fresh after an election, with a new city counsel, and new budget cuts this got put on the back burner. Run until failure. So I could see some families suing the City of Fernie, and with a new election coming up this October I hope the entire counsel gets punted.
I love that these are being made public more often now. I used to work in oil and gas and found many of the safety talks and breakdowns of incidents like this one have helped me keep myself safe in my daily life.
Lessons to take away: Wear your PPE, never disable or silence alarms, avoid going near lethal hazards even if product rots, and WEAR YOUR DAMN PPE. Management won't ensure your safety - it's up to you.
Exactly! Management is not going to care, in fact they are going to place the blame on you for not following training protocol because I know for a fact they have taken safety classes. Those classes immediately shift liability from the company onto you.
@@1989Chrisc he was a refrigeration mechanic who was called later in the day. my guess would be the 2 city workers disabled that alarm while they were venting the building with the firemen. then they called the mechanic to change the oil and went inside with him because they genuinely thought it was safe to do so....they wouldnt have gone in that room if they thought there was a chance they would die
I had this happen when working armed security in Madison Wisconsin. I went to check the pump room and entered the double safety doors. Once I opened the 2nd door the room was full of ammonia vapor. I immediately stopped breathing, closed my eyes, closed the door, opened the first door, and exited to a safe distance before breathing and opened my eyes. I immediately called 911, the facility maintenance, and my security firm. I was alive because of my training.
As someone who worked at an ice rink and was around ammonia, i cannot imagine in any way shape or form how they would even consider trying to restart the compressor. i remember when we had a leak it was around 10 ppm, and it was unbearable to be around. The first reading they got was 300 ppm.... that is insane.
This is why communication and having backup is so important. I can’t believe the system was restarted to save the ice in the rinks, when they could have easily known that was going to spike the ammonia levels once again. And no communication between municipal departments? Did the fire department not inform the city workers that dangerous fumes might be present? Did they not plan to have emergency services there during this obviously dangerous repair? I find it difficult to understand why high school football games have EMS on backup, but none was deployed to a worksite where lethal levels of ammonia were documented the day before.
I can understand silencing the alarm, because the noise could be severely distracting while trying to solve the situation. That doesn't mean to act as if it's no longer a problem, though. continue to behave as if there's still a danger until such time as you can be assured it isn't. And the obvious red flag should have been the levels the ammonia went to in the first place. If you have the alarm set to 35, and it reaches 300, that's a sign there has been a critical failure. I wouldn't have considered the ice itself to be safe either (not knowing just how far or even where the leakage was).
If you know ammonia levels are currently safe and the alarm is still not shutting off, it will do you zero(0) good. Should ammonia levels rise again, the alarm will still be screaming like it was all day, and nobody will know.
They silenced the alarms, and restarted the plant...to save the ice. Unbelievable. The outcome was a fait accompli with stupidity of this magnitude. "The decision to operate the leaking chiller is pivotal in the development of the incident," reads the report. "Once the leaking chiller was put back into operation, additional actions and decisions were a response to cascading failures and were beyond the scope of training and situational awareness of those involved." The regular life expectancy of a chiller is 20 to 25 years. The Fernie chiller was 31 years old when it failed.
The ice is never in contact even with the brine that the ammonia leaked into. Brine is circulated through pipes built into the concrete structure that the ice is built onto.
The silenced alarms would only be a factor for getting an emergency response after the second incident (to warn anyone coming in that ammonia was present), and/or warning that response and anyone else arriving later that there's an ammonia leak. The three crew that died in there, that alarm would be incidental to them because they were hit with a sudden release and not an accumulated gaseous leak. I am surprised that there was a) nobody watching any of the pressure gauges on the chiller system, or b) no automatic pressure release mechanisms. But wasn't there a saline expansion tank? Was there a check valve working against a flow valve here, were the wrong set of valves closed during the emergency? If everything was sealed solid because of the ammonia content in the brine, why was anyone allowed in the building at all until it was stabilized? So yeah, you have it.. nobody understood the system, theory, risks, operation, and hazards well enough to manage the situation at all.
You should’ve called the firefighters to be back for the restartment because they were able to stop the ammonia pipe explosion but were told to leave because of their price
I work in the aircraft maintenance field. When my maintenance control (my supervisors supervisor) told us to rush a job I simply let them know that if I do that we will all be attending at a minimum of 3 extra funerals and that they can explain to a grieving family that it was their fault for wanting to hit quotas that a mother, father, brother, sister, aunt, uncle, cousin, or friend died to save. Something so small for someone to die for. Usually shuts them up. I do my work and I do it right. My other rule is if I wouldn’t send my mother in the plane why the fuck would I send a pilot.
Props to you. It's just like driving, best to assume that everybody else wants you to die. At the end of the day OSHA doesn't amount to shit, and your boss is just thinking about the bottom line. If you aren't looking after your own safety, nobody is.
Interesting. I'm from Indonesia and there're many aircraft accidents here because of similar ignorance. I'm intrigued as to what kind of activities/procedures people in your field often skip in order to meet deadlines?
I'm a firefighter and your videos are invaluable to our safety and training. We have two breweries and a university in our first due response area that have similar ammonia refrigeration systems.
Whoever made the decision to "save the ice" did so at the cost of these mens lives. That person was negligent. And should face the consequences of that decision.
Why are you blaming one person? The workers knew there were deadly levels of ammonia just hours before when the system was running. They still decided to restart the system without any protective equipment. Would you?
No one knew the coupling would fail. If the coupling didn’t fail they would still be alive until the thing had some other mechanical failure and they patched the leak.
@@BaldMancTwat watch the video again around 3:30 it says that they hired an external contactor to replace the oil and before they even got there that the alarm was silencend.
A large part of the problem is people become accustomed to risk. They stop even noticing it after a while. You see it all the time with people like mechanics, electricians, circus performers, and people who work with powered machinery, where they get used to an inherently dangerous situation and begin to take it for granted, not realizing that they are continuing to roll the dice every time, and that their lack of care is increasing the odds of a tragedy with every roll.
I nearly lost a finger on a table saw years ago. It's called complacency. Fortunately I was in no danger of losing my life, but I sure as hell pay attention on the job now.
Very true, im not even close to working with such dangers, other than my own metal fab power tools, but indeed, one must have a level of respect for any type of power tool or machinery no matter what scale of danger.
Hits really close to home. I was an Elkhorn resident and still am a BC resident who knows my worksafe BC rights. Thank you guys. You have saved countless lives
This video is great for illustrating the effects of using *passive voice* in your writing in a way to obscure who acted...or who did not act. A quick example is the active voice, "We made several mistakes" vs the passive voice, "Several mistakes were made." I've noticed a few things in the narration: 1:32 "This *leak was not repaired* during the 2017 summer seasonal shutdown." Whose responsibility was it to repair the leak? 1:52 "On October 16, 2017, at approximately 6:ooam, the *chiller* for the curling rink *was started* and put back into service." Who restarted the chiller? 3:04 "*One of the city workers closed* some of the brine system and ammonia system valves; the shaking stopped." Here the wording uses active voice; probably because the city worker did something productive or effective. 3:13 "The *firefighters vented* the building." Same as before; active voice because of a productive or effective action. 3:23 "A city *worker* then *isolated* the leaking chiller and *shut the system down*." Yep, active voice. 3:34 "The firefighters *were told* they were no longer needed, and left the location between 4:3o and 5:ooam." Now with a bad decision being made, we're back to passive voice. Who told them they we no longer needed? 3:40 "At approximately that time, *it was decided* that the compressors should be restarted in an effort to save the hockey rink's ice." Bad decisions get passive voice. Who *decided*? 3:49 "However, because the compressors' oil had been contaminated with brine, the compressors could not *be restarted* until the oil had been changed." Restarting the compressors is part of the bad ideas category, so it gets passive voice. 4:02 "*An external contractor dispatched* a refrigeration mechanic to the site to change the compressor oil." Active voice, possibly to make it clear *who* sent the mechanic into danger. 4:09 "Prior to the arrival of the refrigeration mechanic, *arrangements were made* to put the ammonia alarm in silent mode for the repairs." This is a big one and probably the best example in this video of using passive voice to obscure just who the actors were. 4:35 "They were not wearing appropriate personal protective equipment and did not have personal monitors for ammonia exposure. There was no backup team, and emergency responders were not present." I included this part because, at least when I watched the video, it seemed to imply that they did not have these resources available, which may have been true. Did the city worker who initially entered the building with the firefighters borrow one of their breathing units, and when they left they took it with them? Perhaps. Of course then you have to ask why a refrigeration mechanic sent to work on a refrigeration system would not have had safety equipment on his service truck. It looks somewhat likely that the three men chose to not wear the gear because they didn't believe they needed it. What happened to these men is awful and I hope their families are doing ok.
It’s probably to avoid defamation lawsuits, and also in the case of the two city workers who perished it might not be clear which of the two was responsible for which actions.
This comment is great for illustrating the effects of the grammar police commenting on something they know little about. Accident investigations, whether it be chemical safety, plane crashes, train crash, are intended to promote safety and prevent reoccurrence, and specifically not to assign blame. Further, there's two sides of every story and some unknowns, so care has to be taken to separate the established facts and things like actions that we aren't certain exactly who did what. Nobody knows who restarted the chiller because everybody who could have is now dead and there wasn't any CCTV or other conclusive evidence. Your brain is going to explode when you see some of the aircraft accident reports where sentences are required to tightly follow a formula. "It is certain that the accident was caused by a fire. It is considered highly probable that the fire was caused by gasoline in checked luggage. It is considered highly probable that the dangerous goods were not detected... It is considered probable that..... It is considered likely that...."
First mistake: Not detecting or repairing pinhole leak during the shut down period. Second mistake: After the leak occurs, and knowing there is a leak, attempting to restart anything without finding the source of the leak and repairing it. Third mistake: Valuing the cost of the ice or the event to be held on the ice over the potential injury or loss of life. I've seen this sort of progression several times over the years. Fortunately, either someone stepped in and injected reason or in the other cases, they got lucky. It is unfortunate, that the lucky cases encourage people to push the bounds of safety. "Do you know what it will cost to shut down the (insert process here)?"
Only comment here that makes sense, everyone is blaming the alarm being silent but that was far from issue. Whoever the hvac tech for that chiller was did a piss poor job
Don’t forget not wearing safety equipment in a potentially hazardous environment, those city workers atleast knew there was potential exposure to dangerous gases but they went in anyways
The leak is easily detectable with scheduled, periodic preventative maintenance inspections. That tank is a tube and shell heat exchanger, and pm tasks should’ve included testing each individual tube with a vacuum tester or with nondestructive testing or X-ray for thickness. Then any that failed should’ve been plugged or or replaced. The company was completely negligent
The two worker dudes failed the oil changer dude. They worked there so they were aware of the dangers. The oil change dude maybe didn’t even know what he was walking into. Sad stuff all around.
Years ago, when I was a paramedic, we got dispatched to a "poisoning" call. Usually it is a child that injested something hazardous, or a snake bite. When we arrived at the meat packing plant, their security had us follow them to approach from the up wind direction. When we came around the corner of the building, there were 60-70 patients laying in the grass outside. Luckily no one died. Nothing like a mass casualty incident to get the adrenaline rush going. EDIT ADDITIONAL: It was a leak of anhydrous ammonia.
My son used to work at a rendering plant in North Carolina. Everyone working there wears a badge with a safety detector to monitor levels of anhydrous ammonia. Last year at their sister site in North Carolina, 2 employees died from exposure to the noxious chemical. My son told me about one of their safety classes, if you smell sweet odor in the air it's already too late. Very dangerous. Thanks for your service in the medical field, we can't manage without y'all!
I know I'm a year late but holy shit. What was the protocol after realizing the situation if you don't mind me asking? I'm going into ems academy this fall, for advanced emt, hazmat, and usar. So naturally this comment peaked my interest.
Man mass cas usually eithe ris going to be the worst most harrowing experience of your life or not that much of a major problem. Never again hopefully.
These illustrations are PERFECT. It's very important to get these illustrations to ALL WORKERS involved with these type of systems.... Work SAFE, people.
Not to be anything but I was very afraid of the Final Mission of Project IGI where if you didn't redip the reactor rods, they'd explode and take the entire map with them.
I worked in the explosives community for 30+ years. Many times I was ridiculed, cursed at, and even laughed at for following established safety protocols. Superiors would get pissed off at the overtime costs, work disruptions, and inconveniences to the community. Even those who WROTE the safety policies would get pissed off when I followed THEIR own policies. But i never wavered. Not once. And because of that, I am here and able to write this constructive critique. Safety protocols are there for a reason. Never, and I mean NEVER , ignore them or take shortcuts. Especially when those who demand you take them, will never be the ones to go downrange. Follow your protocols. Follow your training. Do the job, and DO IT RIGHT. Do that and control the risks. Do that and minimize the dangers. Do that and LIVE.
Same for me in commercial diving. I got ridiculed hard for following safe procedure. "Don't be a pussy, dive like a man" Couldn't deal with it anymore, then several months after I left, there was a fatality at the company I worked at due to negligence and complaceny.
@@jonathanbradley4896 it's a shame that that it takes a man to die to teach others how to do their job safely. Only the colleges learn from it at the company, maybe few others at other companies when they hear from the accident. Maybe those people won't make the same mistake ever again. But others will.
I've worked various aspects of safety and rescue for my entire 24 year career. This is such a horrific failure on so many levels , it's sickening. Prime example of money superseding hse.
I have no idea why but I've become fascinated by post-facto in-depth evaluations of disasters. It almost always ends up being a domino-effect of consecutive failures. Just wanted to say thank you for taking on any risks you did.
There was a case of a train derailment somewhere years ago, and a tanker of anhydrous ammonia spilled. Ammonia gas is heaver than air and at least one family living in a low lying area nearby was overcome in their sleep and died.
It was probably the worker who took that decision and not their management as they know it would have given them the work of having to re do the ice Most management are really conservative when there is risk of industrial accidents
This is so insane! About a month ago, this literally happened to us. My hockey team was in the middle of a game, and ammonia started leaking. Everyone had to evacuate the building and HAZMAT took care of it. Thank goodness the levels where close to 0. Thank the lord no one was injured that day.
The workers were performing "break down maintenance" on a chiller system that was past its useable lifespan. Ammonia leaks had been detected two years prior to the deadly incident, which should have served as an adequate warning to not run it.
I was a security officer at a plant where veggies were processed and flash frozen. I walked into a room with a small ammonia leak one night (I can't recall whether there were ammonia alarms. There certainly wasn't one sounding that night.) Obviously the concentration wasn't deadly but the smell...the burning, acrid smell!! I would have clawed my way through my own grandmother to get away from that shit.
Yeah, the odor threshold for ammonia is so low. I mean, this is how smelling salts work. Unfortunately, that can also be part of how this situation happens, because I would bet there was an odor in that room at all times with that janky old equipment and that the workers were used to it to the point that even though it was likely worse, they didn't recognize just how much of a risk it posed to their safety.
This video is good no doubt. But the th-cam.com/users/uscsb videos are seriously next level! Especially the ones they’ve done the past 12 months, the graphics are so insane you sometimes can’t tell if you’re watching archive news chopper footage, or the computer simulation, I shit you not it’s THAT good!
You’re right, that’s the unfortunate thing. I hate to say it, but complacency and no questioning mindset, I’ve been guilty of it myself. I’m retired now, but I’ve worked in oil refineries, and power plants for for decades, their are very good procedures in place, unfortunately it’s these little pieces of equipment that aren’t up to standards with SOP’s
This isn’t just ammonia it’s anhydrous ammonia and it’s nasty stuff. It absorbs water with anything it touches, including all the water on your body. We had training on it at the fire department. They should’ve never work bunker gear in there let alone let workers in there. They should’ve had Class A HazMat gear. 300 ppm is highly likely to be lethal but when that pipe bursts i bet it got into the 10,000s. Anhydrous ammonia spreads FAST and it’s really nasty stuff. It eats away the skin and dries out the lungs almost instantly and burns them up. Nasty nasty stuff. I hope I never respond to a ammonia leak.
Which is exactly why the arena my husband works at has a policy of immediately calling the manager and city if anything higher than 0ppm is detected and an automatic shutdown of the arena if higher than 5ppm is detected
And just for added flavor, That very same chemical is used for RV Refridgerators. Mine failed while i was sleeping in it and it almost got me. woke up to the odor opened my eyes and was instantly burned. ran out and flushed my face and eyes and dialed 911. Told the fire department what happened and they suited up in Hazmat gear and went in to investigate, sure as hell it was anhydrous ammonia, and i was exposed to more than 300ppm. Fireman said 25ppm is max for humans in a confined area. ambulanced to the hospital for observation. That day i ripped that fridge out of there and installed a 110v fridge. See RV refridgerators work off of absorbtion to cool, also installed a detector. RIP too the Men who lost their lives to this Hazard.
While factually correct, the video is focusing on the action of disabling the ammonia alarm and not wearing PPE during the oil change. But both of those decisions were AFTER the actual mistake: attempting to restart the compressors at all when the system was suffering from 2 serious failures. Either the deadly ammonia leak or the large pressure buildup in the brine system alone is enough of a red flag to keep the system offline until a thorough investigation and repair could be made. Attempting to restart a system suffering from this kind of serious instability is highly negligent.
I really appreciate these animations. It gives a much more detailed recollection than most article posts can, or at leased the visual seems more detailed
It is not stated in the video that any of the responders recognized a breach between the primary/secondary loop. The people who restarted a deranged system without knowing the source of the leak are negligent here. Saving the ice on a curling rink cost the lives of three people. I can only pray I'm worth more than that to my employer...............................................................
Yea its amazing nobody asked "What caused the leak in the first place". A full investigation should have been done and the alarm shouldnt have been silenced period.
Spoiler: You're really not. Safety laws exist because unions fought literal pitched battles with company goons and starved or even laid down their lives to force it on the bosses, not because capitalists are kindly philanthropists.
Here's a hint to your hope: unfortunately none of us are. We are too easily replaced in this over populated world, a world where it is easier/cheaper to import the 3rd world than train people already present in the western world. We have no value to our over lords beyond making them more money.
@@NoJusticeNoPeace There are some out there that go above and beyond with safety. But they're the exception, absolutely not the rule in any way, shape, or form.
This is why health and safety standards need to always be followed. People get too comfortable when they think they’re no longer in danger. Couldn’t have got me near that room until more checks were done, screw the ice lmao. Part of fixing a problem as large as that is asking if it’s not the only part that could have failed and confirming that before starting.
I am an industry insider and respect the investigators involved! How ever I have problems with blaming the service provider called to the scene getting any blame for the events that led to his death! He never started the suspect chiller nor did he close any of the valves. The responsibility lies squarely with the individuals that started the plant and those who knew the chiller had a leak.
JD Lacerte couldn’t agree more. Did the service contractor even know there was a leak in the chiller? Or was he just told change the oil in the compressors and get the system going again.
I didn't interpret this presentation as blaming the service provider or their tech. I agree that it was entirely the fault of the local city/rink workers. Improper training and/or failure to follow safety protocols were the cause(s) of this tragic event.
Once I heard they closed the valves to the overflow tanks, the results were, sadly, predictable since the system was confined at that point. Really should not have allowed the city workers to even touch the equipment. Should have been done by a certified HVAC repair company.
@@sauercrowder it’s almost a certainty. A Canadian town of 4,000 people at 5am. Those workers probably just wanted their local junior team to keep playing. Sadly they didn’t know the dangers.
@@kyleayres6255 lets call workers, that don't know the dangers, into super industrial room with pipes filled with deadly substances. Great idea... just hope, they wont call them into nuclear plant next time.
The narrator should be applauded for 1) Explaining things in a clear and understandable way and 2) not making it all about him like so many other you tube narrators.
As soon as I heard about the pinhole leak at the beginning, I was wondering at which point in the story a weakness in the pipe system will breakdown. There should have been a way to relieve pressure and venting of the compound created. [I just realized from the comments below that the relief valve WAS closed to prevent shaking of the overflow containers]. Well, that's the fatal mistake right there.
Yeah, that’s sad. Whoever closed the valves to the expansion tanks meant well, but that caused the explosion since the brine/ammonia mixture could no longer vent and pressure began building in the system. Besides that though, so many things were done wrong for this to happen.
they should make the pipe leading out of the building, with weakest point installed there. So it breaks up there, outside of building. Of course, surrounded by some safe building from concrete, with alarm. But money talks. It would be safer, but more expensive to build.
As an equipment tech we worked on and around ammonia based systems, let me tell you when we heard those alarms we set Olympic records getting to the safe zones. Even if we knew it was just a drill. That stuff can kill you so fast you no chance of outrunning it.
I was doing my NCSO course when this happened. The information presented in this video is very valuable from a prevention standpoint. Thanks WorkSafeBC for all your hard work. This information helps me on the worksite.
I know I'm just a stupid oul refinery Steamfitter but since when do you allow the cooling fluid to be at a higher pressure than the circulating fluid? I don't even know why alarms can be silenced. Why wasn't a high pressure alarm separate?
Also pressure relief (relief valve/ safety valve) into a reservoir should've been in located in areas prone to high pressures. Especially ones containing highly dangerous chemicals
Under normal operating conditions, the cooling fluid (ammonia) will typically be at a low pressure on the evaporator side of the refrigerator (the side where the circulating fluid passes through tubes which are cooled by the boiling ammonia). Meanwhile, the ammonia on the opposite side of the refrigerator (condenser side) will be at a high pressure. So normally the cooling fluid is at a lower pressure or similar pressure to the circulating fluid. However, when the refrigerator shuts down, there is a tendency for the pressures on the low pressure side and high pressure side to equalize (this is because the compressor has stopped and there is no longer any reason for the refrigerant on the low pressure side to stay at a low pressure). The cooling fluid pressure can then increase above the pressure of the circulating fluid. This is not unusual and the vessels must be designed to account for these high pressures as well as being fitted with pressure safety relief devices. As far as having a high pressure alarm on the brine system; It is not common practice to put a high pressure alarm on the brine side, nor is it required by law. Typically a pressure relief device will be fitted to the brine cycle to prevent high pressure in the cycle. A pressure relief device is typically fitted to the expansion tank, which was isolated in this case and so was not able to relieve the excess pressure in the system, leading to the pipe rupture.
You're proof that safety is a mindset, not a qualification. Far too many "experts" have contributed or caused accidents that logical technicians could see coming a mile away. Nice assessment. Whatever company employs you is lucky to have you.
Water absorbs ammonia. Absorbs a great amount of it actually, and this is a simplified statement, but it wasn't so much that there was ammonia and brine separate in the saline system, it's that the brine absorbed a great deal of ammonia while operating and self-distributed, and it boiled out as the system warmed up. it's like champagne, the colder it is the less CO2 comes out of solution... but get it very hot and the bottle can burst.
One thing I've found from my 8yrs in industrial maintenance is the guys with 25-35 years I've worked with just don't care about any possible risks anymore. Complacency will test your luck till it runs out that's for sure.
Information is the key to everything! When you know about a danger in your work it's highly important to sinalize, tell people, make everything to everybody know that danger.
I feel like the whole rink should have been put on lock down once the original leak was discovered. Whose responsibility that is I'm not sure. Probably the firemen. It being so early in the morning probably didn't help. You discover a leak that patentionally could kill someone, you make it stop leaking then just walk away? Doesn't seem right.
The city workers probably assured the firefighters that everything was fine and they knew what they were doing. It basically says as much in the video.
Alarms: Hey you got a serious problem here, the Ammonia is mixing with the Bri- City Workers: *WE MUST SAVE THE HOCKEY RINKS ICE! PUT THE ALARM ON SILENT MODE!* Alarm: Am I a joke to you?!
1. Always have a back up team when going into a situation that might require immediate assistance 2. Never turn a alarm on silence mode, those things are there for a reason 3. Don't ever rush to get back up and running, be thorough
I remember the Fernie, BC disaster. Unfortunately three municipal workers lost their lives ... I can’t imagine if this had happened with packed hockey & curling arenas during a tournament.
And this is why I had to suffer through a four hour orientation at my last job detailing all kinds of toxic gasses and what to do in an event of leakage and shit...
Thats an horrific incident! The whole system had to be put automaticly OFF after triggering the alarm. (There must be a leak...). The team must find the leak and fix it, before starting the system again. (After doing an pressure test with Nitrogen, for sure.) Heat exchangers need to be cleaned and tested every year (sometimes less, so every 2-5 years). It depends on many things: -The products. (Ammonia might damage the heater) -The pressure and temperatures. (The high temperatures are stressing the metal, checking for small cracks (NDT) is needed!) -Additional: In same cases HTHA (High Temperatur Hydrogen Attack) is possible, in this case it´s not possible. Oh, what did I see? I didn´t saw any safety valve or blow-downs...
What's really depressing is the fact that people have to die (sometimes horribly) to make work environments safer. I always wonder about the families they leave behind... Here one day, gone the next...
"The equipment failed and flooded the building with a lethal dose of ammonia. Lets go back in and turn it on with zero protective equipment after a total of zero repairs have been done."
This is pure idiocy on everyone's part. You take your life in your own hands when dealing with the average person who is unfamiliar with the industrial sector. Safety is number one. Those men knew ammonia was present in its pure, anhydrous form. They should have been prepared. However the city and arena owners are still responsible for the deaths and I hope the families were duly compensated.
So the city supplied all the proper equipment and required the workers to be trained to have the job and they chose not to use the proper equipment and use proper training and you say it's all the cities fault?
omg... I was watching thinking... "oh no they're going to forget to... oh wait no they got it." for the first 3 minutes and 43 seconds... I was like wow this isn't the usual cavalcade of incompetence leading to absurdly avoidable death and lifelong trauma like you see in USCSB videos coming out of the US... And then 3:43 ... yeah this will not end well.
As a person who has worked on homemade fire suppression systems thought I like to test with many problems with corrosion and oxidation I can confirm that these accidents kind of happen a lot especially with pressure not deadly but at the same time mind-boggling. There was one time that I overpressurized a rusted fire extinguisher on accident it didn’t end up badly but it was so bad that the top came off and I got every thing wet so yes I can confirm that things like this can happen and when they do they severely damaged things thank God it was only water but these guys have to deal with ammonia. Even though the alarm was on silent mode you still should’ve had a back up team go in as well as personal protective equipment gas alarm monitors and many other things.
exactly. do not play with gas. that's my experience. sadly, people always underestimate gas problems. we were leakage in one big house full of flats here, and people were smelling the gas like at 6:00am. It finally exploded at the top level, killing 9 people or so. whole house had to be demolished, like 100 people lost their home. workers and owner of the house underestimated situation, he built it secretly other way, to save some money, against safety standards, so gas could accumulate at the top.
Entering a confined space, where there's an ammonium leak and with the sole alarm silenced, that's a recipe for disaster, but the true Final Factor was not using SCBA's and/or having a Safety Team outside the door.
Learn more about managing and reducing the risks of ammonia at: www.worksafebc.com/en/health-safety/hazards-exposures/ammonia
That beeping noise that indicates a lethal hazard? Yeah let's mute that.
I know nobody asked but when i was little, i went to my dads work a lot and stayed in the basement near some alarms, those fucking things didnt shut up for some reason, I might have tinnitus because of it
@@megetrongonzalez4456 lmaooo damn
I mean they already knew there was a lethal hazard
Bit like there is a strange sound coming from your car so you turn up the volume on the radio.
I mean, would it have helped? They *knew* the ammonia levels were above the alarm threshold.
Those pesky alarms....Making lots of racket just to warn of lethal danger....
also, them damn expansion tanks designed into the system to keep it from exploding. shouldn't be able to isolate those.
I hear that, but it would have been going off continuously anyway, negating it's usefulness as the staff was clearly OK with bearing threshold levels...thats common since many alarm systems are set below necessary thresholds-some ridiculously so, I assume for liability reasons (maybe not this one, but people judge by overall experience). I think the real problem here was the city worker's lack of comprehension of the system.....overconfidence in the engineering, lack of understanding of the chemistry involved, etc..
Eiserntors Phantom of the Opera After the firefighters left, the amonia levels never went under the alarm thershold. What difference would it make if the alarm was beeping the whole time?
They took those risks to save ICE.
Shouldn't Canadians work against ICE?
Since the alarm triggered at 35ppm but room concentration only ever dropped to 50ppm after the fire department arrived (which they found to be workable) the alarm would have just went ignored even if they had not shut it off.
I want this dude to narrate all the horrible decisions I've made in my life when I die
"sustained internet usage had sufficiently disrupted the chemical balance within his brain, it was not survivable."
Ya, that'd be fun to listen to.
Charles Freck
I agree. He has erased all trace of judgy from his delivery. In general, I find that family and friends who chastise me, that judgy tone is always there. Like nails on a blackboard.
I’m sure we can arrange that but I don’t know if he has the time to go through that extensive list.
It’s a speech synthesizer
Wow. Props to the editor who decided to play the alarm until "silent mode" and then cut them off. Really effective and emotionally striking, especially in a video with an otherwise detached tone.
It reminds me of that simulation of the titanic sinking in real time for some reason, with all the sounds being prompted. It is really effective.
I know dude, the editor of this clip was a pro. Very good.
Funny that right at that time I was thinking how annoying the sound was and at that moment it turned off
Perfect video
I tuned it out after about 3 beeps and then didn't realize it was going off until he said they turned it off and it stopped.
This happened to my grandfather, the old Chicago Stadium had an ice rink in its basement and he and another worker were using jackhammers to break up the floor of the rink.
The ammonia was supposed to have been drained, but wasn't and when they broke through the pipeline, both were overcome.
My grandfather survived, but spent a year in hospital, but the other worker died.
A year?
My grandfather too
Run on sentence
@@l21n18
Yes, a year, my dad had to quit school and go to work to support the family.
3 different subject in sentence #0 and 2 different subject in sentence #1.
Why does the alarm even have a 'silence' option?
because sometimes you can make an area safe while you make repairs but the alarm still sounds until the leak s repaired.
the fire department should be the only ones with access to the silence button.
All alarm has a silencer
So that you can fix the problem without it blaring at you, the idea being that you only silence the alarm when you actually have a plan to fix the problem.
One reason would be if it's a false alarm because of wiring issues or testing. or if your already aware and working on the issue not much point in keeping the loud ass thing on. they however did it in the worst case possible. they should have at least been monitoring the pressure and should have had personal detection devices they also probably should have worn their PPE and had a crew of fire department outside to keep in touch with them which is what you're supposed to do if you are entering any environments that possible contain hazardous gasses.
false alarms probably. Sensors break.... So they don't have to hear it while working on it too I am sure.
They knowingly risked three lives for the sake of a block of ice.
When you put it that way.. fuck.
Hey, it was a pretty big block of ice!
ceased* They weren't in danger. They're already dead, and the danger was already known b/c of the alarm. There was no risk here. This was due to gross negligence.
Hard to tell if this was gross negligence or gross ignorance.
Thats corporate scumbags for you. Dont care about nothing but money. And it was costing them money having the refrigeration system shutdown. And would have cost them more to replace the ice
Wow...this just looks like a complete rush to restore service. What a tragedy.
Steven Morales don’t want to lose that ice.
..same with most industries.. All of this happened within a short time span.. Should have taken every step as if it were leading to the edge of a cliff.. why the hel did they not monitor the atmosphere the entire time?!
Greed
you idiot. These guys probably didnt make any money based on the arenas profits and were just trying to keep the boss happy. No greed at all
I have some colleagues who responded to the tragedy. What isn't mentioned is that this was this heat exchanger was flagged for replacement, and budgeted for by the City back in 2012. However, fresh after an election, with a new city counsel, and new budget cuts this got put on the back burner. Run until failure. So I could see some families suing the City of Fernie, and with a new election coming up this October I hope the entire counsel gets punted.
"It is critical that the brine and ammonia never mix."
Ohhhh boy, I've seen enough of these videos to know what's going to happen.
Yeah.. It's a horrible, dangerous design.
I love that these are being made public more often now. I used to work in oil and gas and found many of the safety talks and breakdowns of incidents like this one have helped me keep myself safe in my daily life.
Lessons to take away: Wear your PPE, never disable or silence alarms, avoid going near lethal hazards even if product rots, and WEAR YOUR DAMN PPE. Management won't ensure your safety - it's up to you.
Truer words have never been spoken.
lmao
Super relevant in 2020
Exactly! Management is not going to care, in fact they are going to place the blame on you for not following training protocol because I know for a fact they have taken safety classes. Those classes immediately shift liability from the company onto you.
The only people that should have acces to the alarms are the fire department, that it’s self should be a code violation
4:50 most likely the contractors were called in to replace the oil but weren't told there was a leak and needed to be aware.
Like Ed Williams said, you gotta have eyes in your ass in this field...
@@marshalljimduncan that's true for every aspect of life.
They made arrangements for the leak alarm to be silenced.. I can almost guarentee it was the tech who silenced it..
@@1989Chrisc he was a refrigeration mechanic who was called later in the day. my guess would be the 2 city workers disabled that alarm while they were venting the building with the firemen. then they called the mechanic to change the oil and went inside with him because they genuinely thought it was safe to do so....they wouldnt have gone in that room if they thought there was a chance they would die
Exsactly, that's what upsets me the most. That guy died for no reason. In one of the most horrible ways possible. It's so fucked up.
I had this happen when working armed security in Madison Wisconsin. I went to check the pump room and entered the double safety doors. Once I opened the 2nd door the room was full of ammonia vapor. I immediately stopped breathing, closed my eyes, closed the door, opened the first door, and exited to a safe distance before breathing and opened my eyes. I immediately called 911, the facility maintenance, and my security firm. I was alive because of my training.
NOT SO SLIM JIM how did you know the room was full of ammonia vapor when you opened the 2nd door?
Smells like cat piss yeah?
Yup
@@r4z0r84 I've owned lots of rabbits and yeah the ammonia is strong and I can now kinda detect it in low levels
More like your face, eyes, nose, and mouth instantly starts burning.
As someone who worked at an ice rink and was around ammonia, i cannot imagine in any way shape or form how they would even consider trying to restart the compressor. i remember when we had a leak it was around 10 ppm, and it was unbearable to be around. The first reading they got was 300 ppm.... that is insane.
they were wearing protective equipment in first stage, when amonia level was 300 ppm.
after compressor was shat down, they ventilated room.
This is why communication and having backup is so important. I can’t believe the system was restarted to save the ice in the rinks, when they could have easily known that was going to spike the ammonia levels once again. And no communication between municipal departments? Did the fire department not inform the city workers that dangerous fumes might be present? Did they not plan to have emergency services there during this obviously dangerous repair? I find it difficult to understand why high school football games have EMS on backup, but none was deployed to a worksite where lethal levels of ammonia were documented the day before.
Little beans?
Alarms are 100% safe, especially in silent mode...
if you shut it down, you must be prepared like it was on, even if there is no immediate risk.
I can understand silencing the alarm, because the noise could be severely distracting while trying to solve the situation. That doesn't mean to act as if it's no longer a problem, though. continue to behave as if there's still a danger until such time as you can be assured it isn't.
And the obvious red flag should have been the levels the ammonia went to in the first place. If you have the alarm set to 35, and it reaches 300, that's a sign there has been a critical failure. I wouldn't have considered the ice itself to be safe either (not knowing just how far or even where the leakage was).
Given the mode of failure, the alarm wouldn’t have helped them one bit.
If you know ammonia levels are currently safe and the alarm is still not shutting off, it will do you zero(0) good. Should ammonia levels rise again, the alarm will still be screaming like it was all day, and nobody will know.
Yep you don’t have to worry about that alarm injuring anyone
“Ah all’s well that ends well I guess...wait there’s three minutes left in this video...”
I fucking died lol.
“Ah what a well executed fire department training video”
*The alarms were put on silent mode*
“Oh no”
@@donovanchase6086 So did they
LOL LITERALLY
Those workers soon realized they had 3 minutes of their life left
They silenced the alarms, and restarted the plant...to save the ice. Unbelievable. The outcome was a fait accompli with stupidity of this magnitude. "The decision to operate the leaking chiller is pivotal in the development of the incident," reads the report.
"Once the leaking chiller was put back into operation, additional actions and decisions were a response to cascading failures and were beyond the scope of training and situational awareness of those involved."
The regular life expectancy of a chiller is 20 to 25 years. The Fernie chiller was 31 years old when it failed.
Not to mention who knows how much ammonia was leeching into the ice etc.
Money talks, people die.
Another day, another dollar.
The ice is never in contact even with the brine that the ammonia leaked into. Brine is circulated through pipes built into the concrete structure that the ice is built onto.
The silenced alarms would only be a factor for getting an emergency response after the second incident (to warn anyone coming in that ammonia was present), and/or warning that response and anyone else arriving later that there's an ammonia leak.
The three crew that died in there, that alarm would be incidental to them because they were hit with a sudden release and not an accumulated gaseous leak.
I am surprised that there was a) nobody watching any of the pressure gauges on the chiller system, or b) no automatic pressure release mechanisms. But wasn't there a saline expansion tank? Was there a check valve working against a flow valve here, were the wrong set of valves closed during the emergency? If everything was sealed solid because of the ammonia content in the brine, why was anyone allowed in the building at all until it was stabilized?
So yeah, you have it.. nobody understood the system, theory, risks, operation, and hazards well enough to manage the situation at all.
You should’ve called the firefighters to be back for the restartment because they were able to stop the ammonia pipe explosion but were told to leave because of their price
I work in the aircraft maintenance field. When my maintenance control (my supervisors supervisor) told us to rush a job I simply let them know that if I do that we will all be attending at a minimum of 3 extra funerals and that they can explain to a grieving family that it was their fault for wanting to hit quotas that a mother, father, brother, sister, aunt, uncle, cousin, or friend died to save. Something so small for someone to die for. Usually shuts them up. I do my work and I do it right. My other rule is if I wouldn’t send my mother in the plane why the fuck would I send a pilot.
Props to you. It's just like driving, best to assume that everybody else wants you to die. At the end of the day OSHA doesn't amount to shit, and your boss is just thinking about the bottom line. If you aren't looking after your own safety, nobody is.
i 100% relate working in the field also. I rather take delays than send anything off unsafe
An A&P who actually gives a shit? Blasphemy
I fly GA and I thank you sir :)
Interesting.
I'm from Indonesia and there're many aircraft accidents here because of similar ignorance.
I'm intrigued as to what kind of activities/procedures people in your field often skip in order to meet deadlines?
I'm a firefighter and your videos are invaluable to our safety and training. We have two breweries and a university in our first due response area that have similar ammonia refrigeration systems.
Whoever made the decision to "save the ice" did so at the cost of these mens lives. That person was negligent. And should face the consequences of that decision.
Sgt oldschool the guys probably made the decision on their own. We’re talking a town of 4700 people here.
Why are you blaming one person? The workers knew there were deadly levels of ammonia just hours before when the system was running. They still decided to restart the system without any protective equipment. Would you?
No one knew the coupling would fail. If the coupling didn’t fail they would still be alive until the thing had some other mechanical failure and they patched the leak.
They wouldn't have died if they properly followed procedure though
@@BaldMancTwat watch the video again around 3:30 it says that they hired an external contactor to replace the oil and before they even got there that the alarm was silencend.
A large part of the problem is people become accustomed to risk. They stop even noticing it after a while. You see it all the time with people like mechanics, electricians, circus performers, and people who work with powered machinery, where they get used to an inherently dangerous situation and begin to take it for granted, not realizing that they are continuing to roll the dice every time, and that their lack of care is increasing the odds of a tragedy with every roll.
Simply put. Complacency kills
it’s the little thrills in life that make it that much more exciting
I nearly lost a finger on a table saw years ago. It's called complacency. Fortunately I was in no danger of losing my life, but I sure as hell pay attention on the job now.
The acclimation to risk was part of what caused the challenger and Columbia disasters.
Very true, im not even close to working with such dangers, other than my own metal fab power tools, but indeed, one must have a level of respect for any type of power tool or machinery no matter what scale of danger.
Me: I really need to go to bed.
TH-cam: Work safety animation?
Me: ok.
Lmao can relate
⁰
I can't agree with you or keep watching ugh which one
lol
Right? Like, how did this even get recommend to me? Because TH-cam knows I’ll watch anything.
Hits really close to home. I was an Elkhorn resident and still am a BC resident who knows my worksafe BC rights. Thank you guys. You have saved countless lives
This video is great for illustrating the effects of using *passive voice* in your writing in a way to obscure who acted...or who did not act.
A quick example is the active voice, "We made several mistakes" vs the passive voice, "Several mistakes were made."
I've noticed a few things in the narration:
1:32
"This *leak was not repaired* during the 2017 summer seasonal shutdown."
Whose responsibility was it to repair the leak?
1:52
"On October 16, 2017, at approximately 6:ooam, the *chiller* for the curling rink *was started* and put back into service."
Who restarted the chiller?
3:04
"*One of the city workers closed* some of the brine system and ammonia system valves; the shaking stopped."
Here the wording uses active voice; probably because the city worker did something productive or effective.
3:13
"The *firefighters vented* the building."
Same as before; active voice because of a productive or effective action.
3:23
"A city *worker* then *isolated* the leaking chiller and *shut the system down*."
Yep, active voice.
3:34
"The firefighters *were told* they were no longer needed, and left the location between 4:3o and 5:ooam."
Now with a bad decision being made, we're back to passive voice. Who told them they we no longer needed?
3:40
"At approximately that time, *it was decided* that the compressors should be restarted in an effort to save the hockey rink's ice."
Bad decisions get passive voice. Who *decided*?
3:49
"However, because the compressors' oil had been contaminated with brine, the compressors could not *be restarted* until the oil had been changed."
Restarting the compressors is part of the bad ideas category, so it gets passive voice.
4:02
"*An external contractor dispatched* a refrigeration mechanic to the site to change the compressor oil."
Active voice, possibly to make it clear *who* sent the mechanic into danger.
4:09
"Prior to the arrival of the refrigeration mechanic, *arrangements were made* to put the ammonia alarm in silent mode for the repairs."
This is a big one and probably the best example in this video of using passive voice to obscure just who the actors were.
4:35
"They were not wearing appropriate personal protective equipment and did not have personal monitors for ammonia exposure. There was no backup team, and emergency responders were not present."
I included this part because, at least when I watched the video, it seemed to imply that they did not have these resources available, which may have been true. Did the city worker who initially entered the building with the firefighters borrow one of their breathing units, and when they left they took it with them? Perhaps.
Of course then you have to ask why a refrigeration mechanic sent to work on a refrigeration system would not have had safety equipment on his service truck. It looks somewhat likely that the three men chose to not wear the gear because they didn't believe they needed it.
What happened to these men is awful and I hope their families are doing ok.
It’s probably to avoid defamation lawsuits, and also in the case of the two city workers who perished it might not be clear which of the two was responsible for which actions.
This comment is great for illustrating the effects of the grammar police commenting on something they know little about. Accident investigations, whether it be chemical safety, plane crashes, train crash, are intended to promote safety and prevent reoccurrence, and specifically not to assign blame. Further, there's two sides of every story and some unknowns, so care has to be taken to separate the established facts and things like actions that we aren't certain exactly who did what. Nobody knows who restarted the chiller because everybody who could have is now dead and there wasn't any CCTV or other conclusive evidence.
Your brain is going to explode when you see some of the aircraft accident reports where sentences are required to tightly follow a formula. "It is certain that the accident was caused by a fire. It is considered highly probable that the fire was caused by gasoline in checked luggage. It is considered highly probable that the dangerous goods were not detected... It is considered probable that..... It is considered likely that...."
First mistake: Not detecting or repairing pinhole leak during the shut down period.
Second mistake: After the leak occurs, and knowing there is a leak, attempting to restart anything without finding the source of the leak and repairing it.
Third mistake: Valuing the cost of the ice or the event to be held on the ice over the potential injury or loss of life.
I've seen this sort of progression several times over the years. Fortunately, either someone stepped in and injected reason or in the other cases, they got lucky. It is unfortunate, that the lucky cases encourage people to push the bounds of safety. "Do you know what it will cost to shut down the (insert process here)?"
First mistake is allowing that safety culture to make those kinds of decisions or be ignorant to the risks.
Only comment here that makes sense, everyone is blaming the alarm being silent but that was far from issue. Whoever the hvac tech for that chiller was did a piss poor job
Don’t forget not wearing safety equipment in a potentially hazardous environment, those city workers atleast knew there was potential exposure to dangerous gases but they went in anyways
The leak is easily detectable with scheduled, periodic preventative maintenance inspections. That tank is a tube and shell heat exchanger, and pm tasks should’ve included testing each individual tube with a vacuum tester or with nondestructive testing or X-ray for thickness. Then any that failed should’ve been plugged or or replaced. The company was completely negligent
curling is very important in Canada
The two worker dudes failed the oil changer dude. They worked there so they were aware of the dangers. The oil change dude maybe didn’t even know what he was walking into. Sad stuff all around.
Yup they smoked his ass
Years ago, when I was a paramedic, we got dispatched to a "poisoning" call. Usually it is a child that injested something hazardous, or a snake bite. When we arrived at the meat packing plant, their security had us follow them to approach from the up wind direction. When we came around the corner of the building, there were 60-70 patients laying in the grass outside. Luckily no one died. Nothing like a mass casualty incident to get the adrenaline rush going. EDIT ADDITIONAL: It was a leak of anhydrous ammonia.
My son used to work at a rendering plant in North Carolina. Everyone working there wears a badge with a safety detector to monitor levels of anhydrous ammonia. Last year at their sister site in North Carolina, 2 employees died from exposure to the noxious chemical. My son told me about one of their safety classes, if you smell sweet odor in the air it's already too late. Very dangerous. Thanks for your service in the medical field, we can't manage without y'all!
I know I'm a year late but holy shit. What was the protocol after realizing the situation if you don't mind me asking? I'm going into ems academy this fall, for advanced emt, hazmat, and usar. So naturally this comment peaked my interest.
You saved all of those people 🙏🏾🥰
Man mass cas usually eithe ris going to be the worst most harrowing experience of your life or not that much of a major problem. Never again hopefully.
Me no understand
These illustrations are PERFECT. It's very important to get these illustrations to ALL WORKERS involved with these type of systems.... Work SAFE, people.
This is where hours of clicking through TH-cam gets you
Everybody gangsta until the ammonia mixes with the brine.
Lmaooo
Lmao
No shit.
@@mistercarlos5299lool
@Random Number You had us in the first half, not gonna lie
Making a note to share. If you see shaking pipes or tanks in compressor room get the heck out of there. And stay out.
Sound advice sir 😉
Yeah that's no joke! Means that something that isn't supposed to be in there is either boiling or causing the liquid coolant to boil. Not good.
Not to be anything but I was very afraid of the Final Mission of Project IGI where if you didn't redip the reactor rods, they'd explode and take the entire map with them.
I worked in the explosives community for 30+ years. Many times I was ridiculed, cursed at, and even laughed at for following established safety protocols. Superiors would get pissed off at the overtime costs, work disruptions, and inconveniences to the community. Even those who WROTE the safety policies would get pissed off when I followed THEIR own policies.
But i never wavered. Not once. And because of that, I am here and able to write this constructive critique.
Safety protocols are there for a reason.
Never, and I mean NEVER , ignore them or take shortcuts. Especially when those who demand you take them, will never be the ones to go downrange.
Follow your protocols. Follow your training. Do the job, and DO IT RIGHT.
Do that and control the risks.
Do that and minimize the dangers.
Do that and LIVE.
Same for me in commercial diving. I got ridiculed hard for following safe procedure. "Don't be a pussy, dive like a man"
Couldn't deal with it anymore, then several months after I left, there was a fatality at the company I worked at due to negligence and complaceny.
about the last argument, what if i don't want to live?
@@jonathanbradley4896 it's a shame that that it takes a man to die to teach others how to do their job safely. Only the colleges learn from it at the company, maybe few others at other companies when they hear from the accident. Maybe those people won't make the same mistake ever again. But others will.
Remember people: these rules and protocols are written in BLOOD. Someone had to die or get severely injured for this to happen.
What protocols did they want you to abandon
Imagine living your life only to have it boiled down to six words:
*The ammonia levels were not survivable*
_Never silence an alarm. Nerver._
I've worked various aspects of safety and rescue for my entire 24 year career. This is such a horrific failure on so many levels , it's sickening. Prime example of money superseding hse.
Money the root of almost all evil.
I know, wanting to save the ice rather properly fixing or even replacing the equipment cost people their lives.
The poor guys were just trying to save a buck or two for their higher ups ☹
If they were Russian journalists you call Putin an assassinationist for silencing the bad workers
I have no idea why but I've become fascinated by post-facto in-depth evaluations of disasters. It almost always ends up being a domino-effect of consecutive failures. Just wanted to say thank you for taking on any risks you did.
I had no idea artificial ice rinks posed these dangers. This video explained them VERY well...terrible that the video was required though.
These were real ice rinks.
@@bobabooey4537 Yeah hut the ice isn't naturally preasent there
Yeah luckily the arena wasn’t full of people. It’s sad the workers died but luckily no one else did.
There was a case of a train derailment somewhere years ago, and a tanker of anhydrous ammonia spilled.
Ammonia gas is heaver than air and at least one family living in a low lying area nearby was overcome in their sleep and died.
5:28 That moment when you realize your life was valued less than a piece of ice.
Well, it was *hockey* ice, you see, and this was Canada...
Under capitalism, human life must always take a back seat to profits.
@@SuperTonyony 💰💰💰grindset
It was probably the worker who took that decision and not their management as they know it would have given them the work of having to re do the ice
Most management are really conservative when there is risk of industrial accidents
Tony Midyett Government owned and operated, the opposite of capitalism. I believe they call that communism.
This is so insane! About a month ago, this literally happened to us. My hockey team was in the middle of a game, and ammonia started leaking. Everyone had to evacuate the building and HAZMAT took care of it. Thank goodness the levels where close to 0. Thank the lord no one was injured that day.
On what basis do you attribute responsibility for the low ammonia levels to goodness but responsibility the lack of injury to the lord?
@@ParisianWeetabix whats wrong with you? it is said so, with lord. very often.
Uhhh thank the engineers who came up with the ammonia alarm.... but yeah give credit to your imaginary friend
@@Loots1 what’s rammed up your ass? How about thanking no one if you want to be consistent?
@@ParisianWeetabix why not?
The workers were performing "break down maintenance" on a chiller system that was past its useable lifespan. Ammonia leaks had been detected two years prior to the deadly incident, which should have served as an adequate warning to not run it.
I was a security officer at a plant where veggies were processed and flash frozen. I walked into a room with a small ammonia leak one night (I can't recall whether there were ammonia alarms. There certainly wasn't one sounding that night.) Obviously the concentration wasn't deadly but the smell...the burning, acrid smell!! I would have clawed my way through my own grandmother to get away from that shit.
Bet after reading this your grandmother doesn't send you the $5 Christmas card any more.
Yeah, the odor threshold for ammonia is so low. I mean, this is how smelling salts work. Unfortunately, that can also be part of how this situation happens, because I would bet there was an odor in that room at all times with that janky old equipment and that the workers were used to it to the point that even though it was likely worse, they didn't recognize just how much of a risk it posed to their safety.
It’s even more sad to know that properly followed procedures would have saved three lives.
I'm guessing the owner didn't tell them about the ammonia leak. Just told them about the oil mixing
Very sad outcome but an excellent video, on par with the USCSB. Thank you for making these!
This video is good no doubt. But the th-cam.com/users/uscsb videos are seriously next level! Especially the ones they’ve done the past 12 months, the graphics are so insane you sometimes can’t tell if you’re watching archive news chopper footage, or the computer simulation, I shit you not it’s THAT good!
Yes ..same mode
@@Syclone0044 I agree. The US Chemical Safety Board videos are amazing. Thank god they didn't lose all their funding.
Oh no.. That is so sad. My heart goes out to their families.
My dad worked until midnight his live was saved by roughly 4 hours
1. Restart the system without solving the problem. 2. Turn the alarm to silent. 3. Reenter without safety measures.
my mouth dropped when he said they wanted to restart the system.
Obviously, they had no idea of the danger.
You’re right, that’s the unfortunate thing. I hate to say it, but complacency and no questioning mindset, I’ve been guilty of it myself. I’m retired now, but I’ve worked in oil refineries, and power plants for for decades, their are very good procedures in place, unfortunately it’s these little pieces of equipment that aren’t up to standards with SOP’s
This isn’t just ammonia it’s anhydrous ammonia and it’s nasty stuff. It absorbs water with anything it touches, including all the water on your body. We had training on it at the fire department. They should’ve never work bunker gear in there let alone let workers in there. They should’ve had Class A HazMat gear. 300 ppm is highly likely to be lethal but when that pipe bursts i bet it got into the 10,000s. Anhydrous ammonia spreads FAST and it’s really nasty stuff. It eats away the skin and dries out the lungs almost instantly and burns them up. Nasty nasty stuff. I hope I never respond to a ammonia leak.
anhydrous ammonia will shrivel your eyes out your freaking skull
Which is exactly why the arena my husband works at has a policy of immediately calling the manager and city if anything higher than 0ppm is detected and an automatic shutdown of the arena if higher than 5ppm is detected
@@michaelcadena9331 It's like tear gas. I've had whiff of a tiny little whisp of it outdoors. Working on an ammonia AC It knocked me back
And just for added flavor, That very same chemical is used for RV
Refridgerators. Mine failed while i was sleeping in it and it almost
got me. woke up to the odor opened my eyes and was instantly
burned. ran out and flushed my face and eyes and dialed 911.
Told the fire department what happened and they suited up in
Hazmat gear and went in to investigate, sure as hell it was anhydrous
ammonia, and i was exposed to more than 300ppm. Fireman said 25ppm
is max for humans in a confined area. ambulanced to the hospital for observation.
That day i ripped that fridge out of there and installed a 110v fridge. See
RV refridgerators work off of absorbtion to cool, also installed a detector. RIP
too the Men who lost their lives to this Hazard.
Thanx for that, you dodged a bullet...
2:37
“Was it you brine expansion tanks!?”
*tank sweats profusely*
LOL
While factually correct, the video is focusing on the action of disabling the ammonia alarm and not wearing PPE during the oil change. But both of those decisions were AFTER the actual mistake: attempting to restart the compressors at all when the system was suffering from 2 serious failures. Either the deadly ammonia leak or the large pressure buildup in the brine system alone is enough of a red flag to keep the system offline until a thorough investigation and repair could be made. Attempting to restart a system suffering from this kind of serious instability is highly negligent.
It always amazes me how many people will silence an active alarm thinking that solves a problem.
I really appreciate these animations. It gives a much more detailed recollection than most article posts can, or at leased the visual seems more detailed
It is not stated in the video that any of the responders recognized a breach between the primary/secondary loop. The people who restarted a deranged system without knowing the source of the leak are negligent here.
Saving the ice on a curling rink cost the lives of three people. I can only pray I'm worth more than that to my employer...............................................................
Yea its amazing nobody asked "What caused the leak in the first place". A full investigation should have been done and the alarm shouldnt have been silenced period.
Spoiler: You're really not.
Safety laws exist because unions fought literal pitched battles with company goons and starved or even laid down their lives to force it on the bosses, not because capitalists are kindly philanthropists.
Mike Barlow you are just a number on the corporate spreadsheet. That’s the reality of business these days.
Here's a hint to your hope: unfortunately none of us are. We are too easily replaced in this over populated world, a world where it is easier/cheaper to import the 3rd world than train people already present in the western world.
We have no value to our over lords beyond making them more money.
@@NoJusticeNoPeace
There are some out there that go above and beyond with safety. But they're the exception, absolutely not the rule in any way, shape, or form.
As a 21 year old 2nd year plumber gas fitter THANK YOU for posting this and the education
This is why health and safety standards need to always be followed. People get too comfortable when they think they’re no longer in danger. Couldn’t have got me near that room until more checks were done, screw the ice lmao. Part of fixing a problem as large as that is asking if it’s not the only part that could have failed and confirming that before starting.
That’s so upsetting, my condolences to the workers and their families.
I am an industry insider and respect the investigators involved! How ever I have problems with blaming the service provider called to the scene getting any blame for the events that led to his death! He never started the suspect chiller nor did he close any of the valves. The responsibility lies squarely with the individuals that started the plant and those who knew the chiller had a leak.
JD Lacerte couldn’t agree more. Did the service contractor even know there was a leak in the chiller? Or was he just told change the oil in the compressors and get the system going again.
Ah, the old fallacy that any failure has precisely one person to blame, and everyone else is absolutely faultless.
BUT THEY HAD TO SAVE THE RINK ICE!!!@1
Seriously, that is a really fugging stupid reason to risk this.
Was he blamed? I agree, he was innocent and lost his life due to the negligence of the Arena workers.
I didn't interpret this presentation as blaming the service provider or their tech. I agree that it was entirely the fault of the local city/rink workers. Improper training and/or failure to follow safety protocols were the cause(s) of this tragic event.
Once I heard they closed the valves to the overflow tanks, the results were, sadly, predictable since the system was confined at that point. Really should not have allowed the city workers to even touch the equipment. Should have been done by a certified HVAC repair company.
Again, the city workers were specialists in this very area. They were not going in ignorant. We will never know why they made the choices they did.
it was CIMCO refrigeration , worldwide licenced company .......
If they had reopened those expansion tanks valves they probably would still be alive too. They really set themselves up for tragedy.
Whomever gave the order to save the ice and re start the system should have been held criminally liable. Let's hope they were.
It's possible, even likely given it was 4am, that no one gave such an order. Sometimes workers pressure themselves.
@@sauercrowder it’s almost a certainty. A Canadian town of 4,000 people at 5am. Those workers probably just wanted their local junior team to keep playing. Sadly they didn’t know the dangers.
@@kyleayres6255 lets call workers, that don't know the dangers, into super industrial room with pipes filled with deadly substances. Great idea...
just hope, they wont call them into nuclear plant next time.
Ok, your animations have gotten much better, props!!
The narrator should be applauded for 1) Explaining things in a clear and understandable way and 2) not making it all about him like so many other you tube narrators.
Being a municipal maintenance worker, myself, I appreciate these videos (second one I have watched) greatly. This is invaluable stuff!
What a painful torturous way to go. Much like being gassed in the trenches of WWI.
@Turbo Charged Closer than being knifed by your dog.
As soon as I heard about the pinhole leak at the beginning, I was wondering at which point in the story a weakness in the pipe system will breakdown. There should have been a way to relieve pressure and venting of the compound created. [I just realized from the comments below that the relief valve WAS closed to prevent shaking of the overflow containers]. Well, that's the fatal mistake right there.
Yeah, that’s sad. Whoever closed the valves to the expansion tanks meant well, but that caused the explosion since the brine/ammonia mixture could no longer vent and pressure began building in the system. Besides that though, so many things were done wrong for this to happen.
@@ateam505 It's kind of a perfect demonstration of the Swiss Cheese Model.
they should make the pipe leading out of the building, with weakest point installed there. So it breaks up there, outside of building. Of course, surrounded by some safe building from concrete, with alarm.
But money talks. It would be safer, but more expensive to build.
I love how this is recommended when I don’t even know what this is
As an equipment tech we worked on and around ammonia based systems, let me tell you when we heard those alarms we set Olympic records getting to the safe zones. Even if we knew it was just a drill. That stuff can kill you so fast you no chance of outrunning it.
I was doing my NCSO course when this happened.
The information presented in this video is very valuable from a prevention standpoint.
Thanks WorkSafeBC for all your hard work. This information helps me on the worksite.
This scratched that Horror Stories itch for me. The emotionless description of real death; the channels are actually kind of similar.
I got an scp vibe from this
I miss horror stories so bad bro. great channel
I know I'm just a stupid oul refinery Steamfitter but since when do you allow the cooling fluid to be at a higher pressure than the circulating fluid? I don't even know why alarms can be silenced. Why wasn't a high pressure alarm separate?
Also pressure relief (relief valve/ safety valve) into a reservoir should've been in located in areas prone to high pressures. Especially ones containing highly dangerous chemicals
Under normal operating conditions, the cooling fluid (ammonia) will typically be at a low pressure on the evaporator side of the refrigerator (the side where the circulating fluid passes through tubes which are cooled by the boiling ammonia). Meanwhile, the ammonia on the opposite side of the refrigerator (condenser side) will be at a high pressure. So normally the cooling fluid is at a lower pressure or similar pressure to the circulating fluid. However, when the refrigerator shuts down, there is a tendency for the pressures on the low pressure side and high pressure side to equalize (this is because the compressor has stopped and there is no longer any reason for the refrigerant on the low pressure side to stay at a low pressure). The cooling fluid pressure can then increase above the pressure of the circulating fluid. This is not unusual and the vessels must be designed to account for these high pressures as well as being fitted with pressure safety relief devices.
As far as having a high pressure alarm on the brine system; It is not common practice to put a high pressure alarm on the brine side, nor is it required by law. Typically a pressure relief device will be fitted to the brine cycle to prevent high pressure in the cycle. A pressure relief device is typically fitted to the expansion tank, which was isolated in this case and so was not able to relieve the excess pressure in the system, leading to the pipe rupture.
get your refrigeration ticket and it will click
You're proof that safety is a mindset, not a qualification. Far too many "experts" have contributed or caused accidents that logical technicians could see coming a mile away. Nice assessment. Whatever company employs you is lucky to have you.
Water absorbs ammonia. Absorbs a great amount of it actually, and this is a simplified statement, but it wasn't so much that there was ammonia and brine separate in the saline system, it's that the brine absorbed a great deal of ammonia while operating and self-distributed, and it boiled out as the system warmed up.
it's like champagne, the colder it is the less CO2 comes out of solution... but get it very hot and the bottle can burst.
One thing I've found from my 8yrs in industrial maintenance is the guys with 25-35 years I've worked with just don't care about any possible risks anymore. Complacency will test your luck till it runs out that's for sure.
Information is the key to everything! When you know about a danger in your work it's highly important to sinalize, tell people, make everything to everybody know that danger.
I feel like the whole rink should have been put on lock down once the original leak was discovered. Whose responsibility that is I'm not sure. Probably the firemen. It being so early in the morning probably didn't help. You discover a leak that patentionally could kill someone, you make it stop leaking then just walk away? Doesn't seem right.
Yup and they should have done a systems check before booting it up
Mr. Orange ...The fire fighters should have locked down the facility. Until experts can assess the problem.
The city workers probably assured the firefighters that everything was fine and they knew what they were doing. It basically says as much in the video.
Alarms: Hey you got a serious problem here, the Ammonia is mixing with the Bri-
City Workers: *WE MUST SAVE THE HOCKEY RINKS ICE! PUT THE ALARM ON SILENT MODE!*
Alarm: Am I a joke to you?!
Have yoy seen how crazy Canadians get when they can't play they're hockeys?
@@BoleDaPole cry them a river… a river of melted ice…
What an absolutely horrific way to die!!! My prayers and Godspeed for these men and their families!
oh man the audio and animations are incredible
5:41 this immediately conjures the scene when the families are told. Brings a lump to your throat.
1. Always have a back up team when going into a situation that might require immediate assistance
2. Never turn a alarm on silence mode, those things are there for a reason
3. Don't ever rush to get back up and running, be thorough
Sounds like the two workers killed the refrigeration technician with stupidity and complacency.
I remember the Fernie, BC disaster. Unfortunately three municipal workers lost their lives ... I can’t imagine if this had happened with packed hockey & curling arenas during a tournament.
And this is why I had to suffer through a four hour orientation at my last job detailing all kinds of toxic gasses and what to do in an event of leakage and shit...
Not sure why this was suggested to me, but it was very informative.
“It is critical that the brine and the ammonia never mixes”
Me: oh that’s gonna mix isn’t it
“The ammonia leak continued”
Me: *surprised pikachu face*
"It is critical that the brine and ammonia never mix..." Uh oh, I can see where this is going.
Thats an horrific incident!
The whole system had to be put automaticly OFF after triggering the alarm. (There must be a leak...).
The team must find the leak and fix it, before starting the system again. (After doing an pressure test with Nitrogen, for sure.)
Heat exchangers need to be cleaned and tested every year (sometimes less, so every 2-5 years). It depends on many things:
-The products. (Ammonia might damage the heater)
-The pressure and temperatures. (The high temperatures are stressing the metal, checking for small cracks (NDT) is needed!)
-Additional: In same cases HTHA (High Temperatur Hydrogen Attack) is possible, in this case it´s not possible.
Oh, what did I see? I didn´t saw any safety valve or blow-downs...
That's what I'm saying where was the TPRV or presssure reliefs?
What's really depressing is the fact that people have to die (sometimes horribly) to make work environments safer. I always wonder about the families they leave behind... Here one day, gone the next...
"The equipment failed and flooded the building with a lethal dose of ammonia. Lets go back in and turn it on with zero protective equipment after a total of zero repairs have been done."
3:30 Closely watch the orange guy in the middle. He randomly flexes his abs.
Seemed to happen about the time he was told firefighters were no longer needed... lol.
@@KySilverfish isn't that how you communicate with firefighters? Ab flexing?
Hey that Safety Alarm sure is loud, let's turn it off.
You would have turned it off as well. So shut your fucking mouth
You hit a nerve on hedge fund
Rest in peace my fellow workers.
It'd 4am cant sleep, time for another worksafe video.
What an insane failure on so many levels by so many people. Surely people lost their jobs and got jail time?
This is pure idiocy on everyone's part. You take your life in your own hands when dealing with the average person who is unfamiliar with the industrial sector. Safety is number one. Those men knew ammonia was present in its pure, anhydrous form. They should have been prepared. However the city and arena owners are still responsible for the deaths and I hope the families were duly compensated.
So the city supplied all the proper equipment and required the workers to be trained to have the job and they chose not to use the proper equipment and use proper training and you say it's all the cities fault?
They make the "compressor room" sound deadly in the beginning.
I was thinking only 1 compresser room? cos he sad it in a bad way haha
omg... I was watching thinking... "oh no they're going to forget to... oh wait no they got it." for the first 3 minutes and 43 seconds... I was like wow this isn't the usual cavalcade of incompetence leading to absurdly avoidable death and lifelong trauma like you see in USCSB videos coming out of the US...
And then 3:43 ... yeah this will not end well.
As a person who has worked on homemade fire suppression systems thought I like to test with many problems with corrosion and oxidation I can confirm that these accidents kind of happen a lot especially with pressure not deadly but at the same time mind-boggling. There was one time that I overpressurized a rusted fire extinguisher on accident it didn’t end up badly but it was so bad that the top came off and I got every thing wet so yes I can confirm that things like this can happen and when they do they severely damaged things thank God it was only water but these guys have to deal with ammonia. Even though the alarm was on silent mode you still should’ve had a back up team go in as well as personal protective equipment gas alarm monitors and many other things.
Hopefully you care more about your practical work standards, than your writing ...
exactly. do not play with gas. that's my experience. sadly, people always underestimate gas problems.
we were leakage in one big house full of flats here, and people were smelling the gas like at 6:00am.
It finally exploded at the top level, killing 9 people or so. whole house had to be demolished, like 100 people lost their home. workers and owner of the house underestimated situation, he built it secretly other way, to save some money, against safety standards, so gas could accumulate at the top.
I remember helping put the Mamaroneck, (NY) Ice rink together
after work. I had no idea how dangerous doing that was...
"They put the alarm on silent"
Ok I do that too whenever I don't wanna wake up
You might be surprised by just how commonly this is done, because the worker thinks they have determined that the situation is safe.
I love these videos, so informative yet, they have nothing to do with me
Entering a confined space, where there's an ammonium leak and with the sole alarm silenced, that's a recipe for disaster, but the true Final Factor was not using SCBA's and/or having a Safety Team outside the door.
Its likely the contractors who went in later were not told of what happened, they probably thought it was a routine oil change.
@@hajjdawood Yeah, I really doubt that. The ammonia smell would be vicious, even at a safe PPM
Incredible presentation