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 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 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.
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.
..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.
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.
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.
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.
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
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
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
These illustrations are PERFECT. It's very important to get these illustrations to ALL WORKERS involved with these type of systems.... Work SAFE, people.
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.
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.
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.
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 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...."
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 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.
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.
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.
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.
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!
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.
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...
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 really appreciate these animations. It gives a much more detailed recollection than most article posts can, or at leased the visual seems more detailed
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.
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.
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.
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.
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
"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."
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...
Even worse is that the system was flagged to be replaced in 2010, and this happened 7 years later. If they had just replaced it when it was due, this wouldn't have happened.
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...
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.
I am a certified worker member of our JH&SC and an arena worker in the city I live in, I will remember this accident for a very long time to come. Many safety measures were put into place in all our arenas after this incident. My thoughts and prayers go out to all the families of the workers who lost their lives!
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?
We cannot allow the management to sweep a problem like this under the rug. We would like to honor the memory of the workers who have perished due to negligence.
as a former refrig tech, this made me so mad. what the fuck man, poor dude was literally given 0 tools to know his surroundings. bullshit. i hope they were sued to oblivion.
I used to work in a paint factory. Field paint, for painting lines on streets, Parking lots, etc. always had a lot of ammonia and it dried quickly. Since it dried so quickly I would have to go to change the filter because it would get clogged up, the amount of ammonia would almost instantly irritate my eyes and throat so bad, they provided me no ppe to deal with this, I no longer work there.
Thanks for showing this incident . So many contractors are forgotten when it comes to health and safety They are not immune Never enter a situation when your training tells you not to Never bow to pressure from management Be the change
Weird that the ammonia alarm isn't also hooked up to a high capacity blower that would evacuate the vapor upwards or into a secondary holding chamber. It's the first thing the firefighters did.
Ammonia is no joke. I'm a truck driver, and there is one customer we deal with out of the hundreds across North America that uses ammonia refrigeration. Because of that one shipper, we're required to have a full training course on ammonia and it's hazards, regardless of it you'd ever go there. I've never been, but I've needed the course, and two refresher courses
People forget how little money they actually make an hour and take stupid risks for next to nothing. As a city worker these people made roughly $30-$40 an hour I would assume. If someone walked up to them, even with their training, and said "hey...give you $30 to go into this building that's leaking a deadly chemical mixture with no safety equipment and fix a pump. It's cool we silenced the alarm warning you that you could die." I'm positive they would've said no. Everyone would say no. But we have this stupid idea, as conditioned workers and people desperate to earn a living and keep their jobs, that we should do whatever work is asked of us. Because that bullshit $30 an hour took us yeeears to work up to in some cases. So not to get all philosophical about it but we all have a part in deaths like this when we work jobs and forget to ask ourselves "would I do this shit for $15? Would I do it for $30? How about $100?" If not then don't fucking do it.
So what level of pay are you suggesting is right? The workers some situations like this choose to not wear protective equipment or gear. It's not always the company or facility or government. I have been at many site where the senior workers don't do the right thing and juniors want respect of the seniors so the stupidity just carries on. It was not the boss/superviser/municipality, then when the seniors are held accountable the unions jump in and say don't hassle the worker. Time to smarten up universally!
The really appalling thing was the city of Fernie knew the refrigerator system in the arena was in need of replacement as far back as 2012, but kept putting it off.
Incident? More like criminal negligence resulting in deaths. I call it an avoidable tragity. People need to go to prison for this. You kill someone with a gun its usually called murder, with a car, mansluaghter. With deadly poisonous ammonia, ooppsy we had an incident. No! One or more people didn't do their jobs right and they know it and they know what can happen, its at least manslaughter. If it was your husband or brother killed it's not a white washed incident, people need to pay for this or they will do it again.
Imagine that refrigeration mechanic who had no clue what was going on, just got called out by a third party to go do an oil change…if it was early enough, he might not have even woken his family to say bye….
My father worked on commercial tuna ships. That used this same type of refrigeration system back in the day. He developed Parkinson’s and eventually passed from it. But him and I had some talks and he always wondered if him being exposed to Ammonia for all those years played a roll in him getting Parkensons.
Not to minimize the untimely passing of three workers, but this just goes to demonstrate that the US does not have a monopoly on short sighted, greedy tightwads that worship the almighty dollar.
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.
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
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
"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.
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.
“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
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.
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.
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.
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.
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.
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
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
These illustrations are PERFECT. It's very important to get these illustrations to ALL WORKERS involved with these type of systems.... Work SAFE, people.
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
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?
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.
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 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...."
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 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
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.
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.
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.
2:37
“Was it you brine expansion tanks!?”
*tank sweats profusely*
LOL
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.
I love how this is recommended when I don’t even know what this is
As a 21 year old 2nd year plumber gas fitter THANK YOU for posting this and the education
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.
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...
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 really appreciate these animations. It gives a much more detailed recollection than most article posts can, or at leased the visual seems more detailed
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.
That’s so upsetting, my condolences to the workers and their families.
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.
Being a municipal maintenance worker, myself, I appreciate these videos (second one I have watched) greatly. This is invaluable stuff!
This happened to my buddy Eric
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.
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.
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.
oh man the audio and animations are incredible
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
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.
This is pretty scary and sad considering all the workers died to overexposure from Ammonia, effectively suffocating them to death.
Don't know why this suddenly showed up in my feed 4 years later, but still fascinating
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…
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
Companies should just not bother adding alarms if they are just going to be ignored.
"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."
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...
Found this channel now I been watching safety animation videos since 3 am
Rest in peace my fellow workers.
The extremely sad part in is that if they just wore the proper protective equipment, their lives would have been spared.
Even worse is that the system was flagged to be replaced in 2010, and this happened 7 years later. If they had just replaced it when it was due, this wouldn't have happened.
Came here for the animation.
Rest in peace.
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?
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 am a certified worker member of our JH&SC and an arena worker in the city I live in, I will remember this accident for a very long time to come. Many safety measures were put into place in all our arenas after this incident. My thoughts and prayers go out to all the families of the workers who lost their lives!
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?
We cannot allow the management to sweep a problem like this under the rug.
We would like to honor the memory of the workers who have perished due to negligence.
I dont know why this was recommended to me, but I will always make sure to have protection against ammonia exposure.
Preventable.
as a former refrig tech, this made me so mad. what the fuck man, poor dude was literally given 0 tools to know his surroundings.
bullshit. i hope they were sued to oblivion.
They all died suing doesn't benefit anyone
"should never mix" Puts them in the same tubing face to face
Did they just snooze the alarm? 😂
I'm never going ice skating, I'm bad at it any ways
Good analysis
I used to work in a paint factory. Field paint, for painting lines on streets, Parking lots, etc. always had a lot of ammonia and it dried quickly. Since it dried so quickly I would have to go to change the filter because it would get clogged up, the amount of ammonia would almost instantly irritate my eyes and throat so bad, they provided me no ppe to deal with this, I no longer work there.
So nice of Fernie to come together and memorialize something.
Idk how I got to this video but I’m never going to a ice rink again
It'd 4am cant sleep, time for another worksafe video.
Thanks for showing this incident . So many contractors are forgotten when it comes to health and safety
They are not immune
Never enter a situation when your training tells you not to
Never bow to pressure from management
Be the change
Glad someone is making these. The least we can do is learn from our mistakes.
This is so so sad; always trust your gut if you ever feel like something is not right. Risk your pride over your life.
Weird that the ammonia alarm isn't also hooked up to a high capacity blower that would evacuate the vapor upwards or into a secondary holding chamber. It's the first thing the firefighters did.
our alarm is hooked up to a large fan that would carry a lot of it out just into the general outside. but I'm sure not meant for large releases
Lmao they just turn off the fucking alarm and leave without telling the next people anything
Ammonia is no joke. I'm a truck driver, and there is one customer we deal with out of the hundreds across North America that uses ammonia refrigeration. Because of that one shipper, we're required to have a full training course on ammonia and it's hazards, regardless of it you'd ever go there. I've never been, but I've needed the course, and two refresher courses
This is very sad. Three lives were lost. May God comfort their families
People forget how little money they actually make an hour and take stupid risks for next to nothing. As a city worker these people made roughly $30-$40 an hour I would assume. If someone walked up to them, even with their training, and said "hey...give you $30 to go into this building that's leaking a deadly chemical mixture with no safety equipment and fix a pump. It's cool we silenced the alarm warning you that you could die." I'm positive they would've said no. Everyone would say no. But we have this stupid idea, as conditioned workers and people desperate to earn a living and keep their jobs, that we should do whatever work is asked of us. Because that bullshit $30 an hour took us yeeears to work up to in some cases. So not to get all philosophical about it but we all have a part in deaths like this when we work jobs and forget to ask ourselves "would I do this shit for $15? Would I do it for $30? How about $100?" If not then don't fucking do it.
So what level of pay are you suggesting is right? The workers some situations like this choose to not wear protective equipment or gear. It's not always the company or facility or government.
I have been at many site where the senior workers don't do the right thing and juniors want respect of the seniors so the stupidity just carries on. It was not the boss/superviser/municipality, then when the seniors are held accountable the unions jump in and say don't hassle the worker.
Time to smarten up universally!
30$ per hour? Jesus I work in a lead/acid battery plant in Italy as manteinance and I make 7€/h
come to the US. Standard maintenance pay in a major city would be 30-40 hr.
From the CBC article, it states that the life expectancy of a chiller is 20-25 years. The Fernie Memorial Arena's chiller was 31 years old.
The really appalling thing was the city of Fernie knew the refrigerator system in the arena was in need of replacement as far back as 2012, but kept putting it off.
Incident? More like criminal negligence resulting in deaths. I call it an avoidable tragity. People need to go to prison for this. You kill someone with a gun its usually called murder, with a car, mansluaghter. With deadly poisonous ammonia, ooppsy we had an incident.
No! One or more people didn't do their jobs right and they know it and they know what can happen, its at least manslaughter. If it was your husband or brother killed it's not a white washed incident, people need to pay for this or they will do it again.
johnross1947 I don't think you know the definition of murder.
You can't put dead people in prison.
Imagine that refrigeration mechanic who had no clue what was going on, just got called out by a third party to go do an oil change…if it was early enough, he might not have even woken his family to say bye….
Who else watched this 2 years ago and youtube recommended it to you again?
Many of the incident i saw on the internet caused by worker ignoring or shutting off the alarm, including plane crash too.
Whoever shut off those alarms, should be held accountable for manslaughter
if i was the family of those victims i would not want to be any of the maintenance workers responsible for this accident. heads would roll
This was absolutely riveting.
My father worked on commercial tuna ships. That used this same type of refrigeration system back in the day. He developed Parkinson’s and eventually passed from it. But him and I had some talks and he always wondered if him being exposed to Ammonia for all those years played a roll in him getting Parkensons.
Cuz you know. Hockey takes precedence over safety in Canada. Gotta keep the rinks ready.
Not to minimize the untimely passing of three workers, but this just goes to demonstrate that the US does not have a monopoly on short sighted, greedy tightwads that worship the almighty dollar.
WOW!! So easily preventable...very sad.
I don't really know why but I find these videos really intriguing. Seeing how they solve the mystery with high stakes
So don't put an alarm that's designed to save your life on silent mode and don't try to save ice coz it's worth less than life.
They must hire the same guy to narrate gov't reports, trainings, and How It's Made.
Whoever decided and/or disarmed the ammonia alarm should be charged with involuntary manslaughter.
1000 ways to die #580 save the ice 🧊
i dont like ammonia he is a bad guy
But he's the cool guy.
I heard he’s chill