The Importance of Safety Protocols: Lessons from a Fatal Ammonia Leak


The recent fatal ammonia leak at an Arctic Glacier Inc. facility in Kamloops, British Columbia, serves as a grim reminder of the critical importance of safety protocols in the power engineering industry. This incident led to a fatality, multiple ammonia exposures, a local evacuation, and an extended business shutdown. In this post, we’ll delve into the findings of Technical Safety BC’s investigation and discuss key takeaways to prevent similar tragedies.

The Incident:

On May 26, 2022, a crew was disassembling two ammonia refrigeration systems, believing that all ammonia had been removed. However, a valve was turned, releasing a large amount of ammonia. The individual who turned the valve was fatally affected, marking this as a fatal ammonia leak that had far-reaching consequences.

The Investigation:

Technical Safety BC identified that the primary cause of the fatal ammonia leak was the failure to remove ammonia from the system before disassembly. Contributing factors included:

  • Miscommunication and changes in personnel
  • Ineffective assessments to identify hazardous quantities of ammonia
Equipment and Environmental Considerations:

The investigation also found that certain equipment modifications increased the risk during disassembly. For instance, a quarter-turn ball valve had been added, which allowed for a rapid and uncontrolled release of ammonia when opened. Additionally, up to 1,600 lbs of ammonia was released into the atmosphere, posing serious environmental concerns.

Lessons Learned:
  1. Qualified Personnel: Always ensure that qualified personnel are involved in hazardous operations. In this case, the absence of a qualified refrigeration mechanic contributed to the tragedy.

  2. Effective Communication: Never assume that safety protocols have been followed. Misunderstandings can lead to fatal errors, as was evident in this fatal ammonia leak.

  3. Regular Assessments: Qualified mechanics should regularly assess systems to prevent misunderstandings that lead to accidents. In this incident, ineffective assessments contributed to the tragedy.


This tragic incident underscores the need for stringent safety protocols and effective communication in the power engineering industry. As we mourn the loss of a life, let’s commit to learning from this event to prevent future tragedies. The fatal ammonia leak at the Arctic Glacier facility should serve as a wake-up call for all of us in the industry to revisit and reinforce our safety measures.

Read the full investigation report here

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