Innovation March-April 2023

F E A T U R E

O n May 26, 2022, between 1,345 and 1,600 pounds of ammonia were suddenly released from a de-commissioned refrigeration system, killing the man who opened the valve. Those dismantling the equipment believed the tank had been emptied years earlier. A report released in January by Technical Safety BC (TSBC) investigators into the incident at an Arctic Glacier location in Kamloops, found a chain of missteps over a number of years led to the deadly mistake. Lead investigator with TSBC Jeff Coleman, P. Eng., said dangerous situations are often the sum of oversights, mistakes, and miscommunications that add up over years of day-to-day decisions. That was the case in Kamloops, said Coleman, director of technical programs at TSBC. “People may not have understood the potential impacts. It’s not always clear. It’s not always black and white; it’s very grey—and it’s very subject to hindsight bias,” he said.

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