# Natural Gas Explosion at Educational Facility

**Citation:** DCA17MP007  
**Type / status:** incident / current  
**Agency:** National Transportation Safety Board  
**Effective:** 2017-08-02  
**Published:** 2021-05-18

Accident. in Minneapolis, MN, USA. on 2017-08-02. CenterPoint Energy Minnesota Gas. Leak/explosion/fire

## Document text

NTSB investigation DCA17MP007.

Event Type: Accident

Event Date: 2017-08-02

Event City: Minneapolis

Event State Or Region: MN

Event Country: USA

Pipeline Operator: CenterPoint Energy Minnesota Gas

Accident Type: Leak/explosion/fire

Completion Status: Completed

Report Number: PAB1903

Report Date: 2020-01-02

Probable cause: The National Transportation Safety Board determines that the probable cause of the natural gas explosion at the Minnehaha Academy was the disassembling of piping upstream of a gas service meter in the building by a pipefitting crew, resulting in the release of natural gas, which subsequently ignited. Contributing to the accident was the lack of detailed documentation that clearly established the scope of work to be performed.

Tier1Name: Initiating product flow

Tier2Name: Pressure/flow control malf/failure

Tier1Name: Post-release

Tier2Name: Explosion

Tier1Name: Post-release

Tier2Name: Evacuation

Tier1Name: Post-release

Tier2Name: Fire

Tier1Name: Emergency response

Tier2Name: Emergency shutoff

Tier1Name: System operating, changing flow/pressure

Tier2Name: Product leak/release

Tier1Name: System maintenance

Tier2Name: Maintenance event

Tier1Name: System not operating

Tier2Name: Servicing event

Finding Tier1Name: Organizational

Finding Tier2Name: Support/oversight/monitoring

Finding Tier3Name: Documentation/record keeping

Finding Modifier Name: Other institution/organization

Finding Report Text: Organizational - Support/oversight/monitoring - Documentation/record keeping - Other institution/organization

Finding Tier1Name: Environment/Infrastructure

Finding Tier2Name: Operating environment/control system

Finding Tier3Name: Product control system

Finding Modifier Name: Effect on equipment

Finding Report Text: Environment/Infrastructure - Operating environment/control system - Product control system - Effect on equipment

Finding Tier1Name: Personnel

Finding Tier2Name: Action/decision

Finding Tier3Name: Information processing/decision making

Finding Modifier Name: Other company personnel

Finding Report Text: Personnel - Action/decision - Information processing/decision making - Other company personnel

Official NTSB investigation data. NTSB findings determine probable cause and make safety recommendations; they do not adjudicate civil liability or regulatory violations.

What Happened
On August 2, 2017, at 10:22 a.m., local time, a building on the north campus of the Minnehaha Academy, a private school in Minneapolis, Minnesota, was destroyed by a natural gas explosion. At the time of the explosion, two workers were installing piping to support the relocation of gas meters from the basement of the building to the outside. Two new meters mounted on an exterior wall were ready for the piping to be connected. While workers were removing the existing piping, a full-flow natural gas line at pressure was opened. The workers were unable to control the release of the gas; thus, they evacuated the building and warned others to evacuate. The explosion occurred during their evacuation. Two individuals were killed, and nine others were injured.

What We Found
We determined that the probable cause of the natural gas explosion at the Minnehaha Academy was the disassembling of piping upstream of a gas service meter in the building by a pipefitting crew, resulting in the release of natural gas, which subsequently ignited. Contributing to the accident was the lack of detailed documentation that clearly established the scope of work to be performed.

PAB-19-03
<<<PAGE 1>>>

National Transportation Safety Board
Pipeline Accident Brief
Natural Gas Explosion at Educational Facility
Minneapolis, Minnesota
August 2, 2017
The Accident
On August 2, 2017, at 10:22 a.m., local time, a building on the north campus of the
Minnehaha Academy, a private school in Minneapolis, Minnesota, was destroyed by a natural gas
explosion. Figure 1 shows an aerial view of the north campus prior to the accident, with a yellow
arrow pointing toward the explosion site. Figure 2 is a photograph of the accident site taken after
the building explosion, with emergency responders and gas company personnel on scene. At the
time of the explosion, two workers were installing piping to support the relocation of gas meters
from the basement of the building to the outside. Two new meters mounted on an exterior wall
were ready for the piping to be connected. While workers were removing the existing piping, a
full-flow natural gas line at pressure was opened. The workers were unable to control the release
of the gas; thus, they evacuated the building and warned others to evacuate. The explosion occurred
during their evacuation. Two individuals were killed, and nine others were injured.1
1 For more detailed information about this accident investigation and documents referenced in it, see the National
Transportation Safety Board’s (NTSB) public docket at https://www.ntsb.gov/investigations/SitePages/dms.aspx and
search for accident number DCA17MP007.
60032 NTSB/PAB-19/03
This report was reissued on December 6, 2019, with corrections to the Probable Cause on page 10.
This report was reissued on January 2, 2020, with corrections to the section on the Minnesota Public Utility Commission on page
9.

<<<PAGE 2>>>

Minneapolis Natural Gas Explosion
Figure 1. Photograph of north campus area at Minnehaha Academy prior to explosion. (Source:
minnehahaacademy.net.)
Figure 1. Photo of accident site taken after building explosion. (Source: Minneapolis Fire
Department.)
The Accident Site
Minnehaha Academy was in recess for summer vacation, but 36 Academy staff were
present to perform administrative tasks. Six students and the basketball coach were in the
gymnasium. The basement of the central building structure contained a utilities/storage room, a
boiler room, and a “utility bunker.” The utility bunker was an extension of the basement spaces
constructed beneath a ground-level concrete slab that extended out from the west basement wall
of the building. The utility bunker, which was outside the foundation footprint of the building,2

<<<PAGE 3>>>

Minneapolis Natural Gas Explosion
contained the gas service meter equipment and was accessed by a basement door from the boiler
room.
CenterPoint Energy Minnesota Gas
Natural gas was supplied to the school by CenterPoint Energy Minnesota Gas (CPEMG).
CPEMG performed maintenance on its own natural gas service meters and distribution pipelines
and also hired contractors to perform specialized pipefitting services. The maintenance activity on
the day of the accident was being performed by such a contractor.
Gas was supplied to the school through two meters, an arrangement that allowed the gas
company flexibility in its ability to supply gas to customers. When the demand for natural gas is
high (for example, when outdoor temperatures are cold) and CPEMG may need delivery capacity
elsewhere in its system, CPEMG offers commercial customers the option, if they have the ability,
to use either natural gas or, alternately, some other form of fuel such as fuel oil. CPEMG may offer
the customer advantageous pricing if the customer is willing to shift to the alternate fuel at that
time. CPEMG supports this alternate fuel supply arrangement by the installation of (1) a “firm”
customer gas meter that supplies a continuous source of gas for appliances that require an
uninterruptable gas supply, such as for hot water or cooking, and (2) an “interruptible” customer
gas meter that can interrupt (temporarily suspend) the flow of gas that would supply appliances
such as large boilers, where the appliance can be readily switched over to the alternate fuel source.
Minnesota Office of Pipeline Safety
Jurisdictional pipes fall under the Minnesota Office of Pipeline Safety (MNOPS) for safety
oversight to ensure enforcement for construction, operations, and maintenance pursuant to Title 49
Code of Federal Regulations (CFR) Part 192 Transportation of Natural and Other Gas by Pipeline
– Minimum Federal Safety Standards. Non-DOT jurisdictional pipes (also called customer pipes)
do not fall under federal requirements; instead, these pipes belong to the gas customers and are
constructed under permit from the local jurisdiction. Generally, customer piping within a facility
up to the outlet of the service meter are nonjurisdicational; whereas, from the service meter
outward to the distribution system, they are jurisdicational.
Master Mechanical, Incorporated
Master Mechanical, Inc. (MMI) was the contractor hired by CPEMG to perform the
pipefitting work at the accident site. MMI is a professional mechanical contracting company, based
in Eagan, Minnesota, that has about 125 employees; the technical field personnel were hired
through local unions, which provided apprenticeship training programs.
The MMI work involved a project to relocate the gas service meters from the inside of the
building to the outside of that building. The construction print ticket for the specific phase of the
project involving the MMI personnel on the day of the accident included connecting CPEMG’s
relocated meters using 2-inch black threaded gas piping, welding 4-inch gas piping, welding
underground pipes, conducting core-drilling as necessary, performing the work during normal
business hours, and securing the Minneapolis city permit for the work. About a month prior,
CPEMG had installed two new sets of gas service meter equipment on the outside of the building.
3

<<<PAGE 4>>>

Minneapolis Natural Gas Explosion
The MMI on-site work crew consisted of a field foreman and a construction helper; the
field foreman was the father of the construction helper. The field foreman was trained to the job
classification level of a journeyman/pipefitter, and he was hired by MMI in March 2009 and had
worked there about 8 years. He had held the journeyman/pipefitter job classification for about 5
years. Although the journeyman/pipefitter was licensed and trained to meet state and local
requirements, he was not qualified to work on DOT-jurisdictional piping. He had not completed
the CPEMG Operator qualifications program, as required by 49 CFR Part 192, Subpart N, to work
on the covered tasks associated with jurisdictional piping.
The construction helper, who was working on the gas piping immediately preceding the
explosion, was a part-time employee. He was not trained to any pipefitter job classification level.
He was initially hired by MMI in June 2015, departing and returning to the company in
January 2017. At the time of the accident, the construction helper had been in that job position for
less than 6 months, with total accumulated work experience with MMI of a little more than
8 months. The construction helper also had not completed the CPEMG operator qualifications
program.
CPEMG contracted with MMI to perform piping modifications to support the relocation of
the gas meters from inside the building to the outside of the building. Normally, CPEMG would
send a contract work request to MMI, which would then respond by sending CPEMG an
acceptance letter to execute the project at a cost, which would then become the contract agreement.
However, for the Minnehaha Academy Upper School meter relocation project, the CPEMG stated
contract with MMI was the MMI proposal (work bid) for the project. The written terms of the
contract were as follows:
MMI would:
• Connect CPEMG’s relocated meters to the building
• Use 2-inch black threaded gas piping
• Weld 4-inch gas piping
• Weld underground pipes
• Conduct core drilling as necessary
• Perform the work during normal business hours
• Secure the Minneapolis City permit for the work
MMI would not:
• Paint
• Start-up or re-light customer equipment
• Pressure test customer piping
• Work overtime
• Demolish piping,
• Work on existing meter
• Dig underground
There was no additional or specific written documentation on the terms of the proposal.
4

<<<PAGE 5>>>

Minneapolis Natural Gas Explosion
On the day of the accident, the two-person MMI pipefitting contractor crew was making
modifications to piping upstream of the firm and interruptible meters, meaning the two-person
crew was working on jurisdictional piping. Figure 3 is a photo taken before the accident showing
the vault area of the center section of the building basement and describing the individual damaged
piping elements involved in the accident. The photo depicts the location of the nonjurisdictional
section of gas pipe and the jurisdictional piping that was being dismantled by the contractor work
crew during the accident.
Figure 3. Photo taken before the accident of vault area of the center section of the building
basement. (Source: CPEMG.)
Natural Gas Service System
Natural gas service to the school could be shut off using the manually operated customer
service valve (also known as a curb valve or fire valve), which was located in an underground
valve box (also known as a curb box). Beyond the curb valve, the natural gas supply line penetrated
the utility bunker wall and branched to supply gas to the firm and interruptible meters. The branch
to the interruptible meter passed through a manually operated plug valve (involved in the accident),
manufactured by The Walworth Company. The end of the plug is square, for attachment of a handle
having a compatibly sized opening to accommodate the square stub on the plug. The handle can
be attached in any of four different orientations. The square hole of the handle was also equipped
with a setscrew to lock the handle in place. The plug in the valve turns 90 degrees; in one
orientation, a passage through the plug aligns with the attached piping and gas can flow; when
5

<<<PAGE 6>>>

Minneapolis Natural Gas Explosion
turned 90 degrees, to achieve the closed position, the passage is perpendicular to the attached
piping and gas cannot flow.
Both the curb valve (outside the accident building) and the 3-inch Walworth plug valve
(located in the utility bunker) were part of the “distribution system,” and as such, both comprised
the “regulated” section of the gas service pipeline. The Walworth Lubricated Plug Valve (product
line) service manual for the type of plug valve involved in the accident recommends that the in-
service valve be periodically lubricated, although there is no specific time when such maintenance
should be performed.
CPEMG maintenance records reviewed during the investigation indicated the following:
• Maintenance on the customer curb valve was performed at least three times in the
5 years prior to the accident (in December 2012 and twice in November 2013);
however, no notations were cited in the documentation that indicated the operating
conditions of the curb valve or specific maintenance activities that were performed
on that curb valve.
• CPEMG provided documentation of the following activities which CPEMG
indicated would have required the Walworth plug valve to be exercised: an
interruptible meter oil change that took place on December 2, 2011, a pressure test
associated with the service line replacement in 2002, and a pressure test associated
with the installation of a Kerotest valve in 1971. CPEMG further indicated that
meter oil changes would have been completed about every 5 years since the plug
was installed in 1959.
Activities Immediately Preceding the Explosion
On the day of the accident, the MMI field foreman and construction helper were at the job
site to perform the piping relocation work. CPEMG did not have any employees at the job site at
the time of the explosion; the closest CPEMG employee was a block away in a company vehicle
awaiting arrival of a construction vehicle that was enroute to the job site.
National Transportation Safety Board (NTSB) interview statements by the two MMI
employees indicated that, prior to the explosion, they had encountered a plug valve that was
connected to and located immediately prior to the interruptible meter in which the wrench was
“stuck” in the closed position (that is, the wrench could not be turned). The construction helper
stated that he knew the valve was closed because the wrench was positioned perpendicular to the
valve piping (the inlet/outlet connection ports of the valve).
The field foreman also stated that he had determined that the plug valve was closed and
that it was safe for the construction helper to begin dissembling piping downstream of the valve.
Based on NTSB interviews, upon instruction from the field foreman, the construction helper,
working alone in the utility bunker, was then assigned to disconnect the piping from the
interruptible gas service meter
A school maintenance worker located on a floor above the basement heard a “horrendous
flow of air,” and he immediately went to investigate the strong odor of natural gas and the loud
noise coming from the basement. As he exited the basement, he made an announcement over his
6

<<<PAGE 7>>>

Minneapolis Natural Gas Explosion
handheld radio that there was gas in the building and to evacuate immediately. As he made his
radio announcement, he ran up the stairs and searched for occupants. Less than 1 minute later, the
building exploded.
Emergency Response
At 10:23:06 a.m., the Minneapolis Emergency Communications Center received a call
reporting the incident, which was initially described as a building collapse. After several
subsequent 9-1-1 calls, this was amended to an explosion with fire response, in which it was also
indicated “2 people were buried under a wall.
” The Minneapolis Fire Department (MFD) was
dispatched at 10:24:39 a.m., and the first unit arrived at 10:30:57 a.m. The MFD response
eventually totaled 31 emergency services vehicles and at least 79 MFD personnel. The
Minneapolis Police Department was also dispatched to the scene. The arriving MFD personnel
observed debris in the parking lot in front of the school building and reported a “strong odor of
gas” in that area. They also observed a structural collapse of a section of the school building, with
an ensuing fire within the collapsed structure debris, along with numerous blown out windows in
the remaining noncollapsed sections of that building.2
An apparent free flow of burning natural gas was occurring beneath the debris pile of the
collapsed structure, which resulted in an inability to suppress the fire. The curb valve was beneath
debris remnants of a collapsed brick wall, which was cleared by on-scene personnel; CPEMG
closed this valve at 11:18 a.m. The fire was subsequently suppressed by firefighters.
Summary of Damage/Injuries
The estimated total property damages resulting from the explosion and fire were about
$30 million.
3 Two individuals were killed, and nine were injured as a result of the explosion and
fire. The injured were transported to local medical facilities by the jurisdictional ambulance
services for medical evaluation and/or treatment. About 42 staff members and students, were
evacuated from the school immediately prior to the explosion.
The Investigation
Examination of Plug Valve
The on-scene examination by the NTSB of the plug valve, which the two MMI on-site
employees had identified as having been “stuck” in the closed position, showed that the valve
wrench was positioned perpendicular to the piping. Disassembly of the valve components showed
that the internal “flow control” component of the valve (the valve plug) was in the open position.
The investigators were unable to determine how the valve wrench became positioned in that
perpendicular orientation because preaccident photographs, provided by CPEMG and taken about
2 Minneapolis Fire Department Incident Detail Report(s): Incident Number(s) 17-0028219 and 17-0028220 and
interview (transcript) testimony of several witnesses to the emergency response at the scene, available in the NTSB
public docket at https://www.ntsb.gov/investigations/SitePages/dms.aspx by searching for accident number
DCA17MP007.
3 PHMSA Incident Report (Form F7100.1): Gas Distribution System, Number 20170111-16716, dated December
5, 2017.
7

<<<PAGE 8>>>

Minneapolis Natural Gas Explosion
1.5 years prior to the accident, showed the wrench positioned parallel to the piping, thus indicating
the valve was open.
It is customary to align the handle so that it is parallel with the piping when the valve is
open and positioning the handle perpendicular to the piping when the valve is closed. However,
confirmation of this is the responsibility of the crew working on the piping. This confirmation
would entail removal of the handle and noting the position of plug assembly and viewing the
indicator or witness mark on the body of the valve.
Briefly summarized, the NTSB Materials Laboratory report indicated (1) the valve wrench
was found oriented perpendicular to the valve body, (2) the valve plug was oriented in the open
position, (3) “witness marks” were found on two surfaces of the valve stem that were consistent
with contact by a valve wrench set screw, (4) the valve stem collar had embossed arrows indicating
the state of the valve (open or closed), in which the arrows were oriented parallel to the direction
of flow, which was consistent with the valve being open, and (5) measurements of 344 and then
152 foot-pounds of torque were required to rotate the valve wrench (handle) of an exemplar plug
valve, which compared to a measurement of 721 foot-pounds of torque that was applied to the
wrench (handle) of the accident plug valve that had been exposed to the fire and had a 4-foot
extension attached to the wrench (for additional leverage), in which no rotation was achieved.
Postaccident Actions
Following the accident, CPEMG took action to improve the safety of its work activities,
which was documented to the investigation as follows.4
Following the incident, Minnesota Gas [CPEMG] suspended company-initiated
commercial meter moves from inside to outside. Over a period of several months,
a cross-functional team including representatives from operations, engineering,
purchasing, and compliance reviewed the existing process and ultimately
recommended the following actions to improve project oversight, project
documentation, and internal and external project communications. Minnesota Gas
implemented these recommendations and has used the revised process several times
now to successfully complete company-initiated commercial meter moves from
inside to outside. The implemented initiative actions are briefly summarized as
follows:
• Formally document the process for company-initiated commercial meter moves
from inside to outside, beginning with identification of project need through
completion in the field and assigning responsible parties for each step in the
process, with oversight provided by a project manager who is accountable for
the project in which––
o The revised process includes written and verbal communications to
affected customers throughout the project; multiple checkpoints with
customers and mechanical contractors to coordinate work; defining the
4 E-mail correspondence from CPEMG to NTSB, dated July 26, 2019 (mostly quoted verbatim).
8

<<<PAGE 9>>>

Minneapolis Natural Gas Explosion
demarcation point between utility facilities and customer piping; and
discussing when, where, and how gas will be turned off;
o Based on feedback from the customer and through engineering review,
a plan is tailored to meet the customer’s unique needs and to carry out
the work at each location; and
o On the tie-in day, a group safety meeting will be held at the worksite
involving all parties (Minnesota Gas, customer, and mechanical
contractor) to go over the plan, review each party’s responsibilities, and
clarify any questions.
 Train and provide instruction to Minnesota Gas management, engineering, and
field personnel on the revised process; the company’s expectations; and their
respective roles and responsibilities, with update and refresher training as
needed.
 Send a letter annually to licensed mechanical contractors regarding the
demarcation point between Minnesota Gas facilities and customer piping and
reiterate they are not authorized to work on or operate Minnesota Gas facilities.
 For residential customers, information about the demarcation point between
utility facilities and customer piping has also been published on the company’s
external website at https://www.centerpointenergy.com/en-
us/residential/safety/meter-safety?sa=mn.
Minnesota Public Utility Commission Action
In response to the Minnehaha Academy accident and several similar prior natural gas
release and explosion accidents, the Minnesota Public Utility Commission (MN-PUC) issued a
memorandum, dated March 20, 2019, titled “Gas Utility Installation of Excess Flow Valves and
Manual Service Line Shutoff Valves,” which described the new requirements of the MN-PUC,
regarding the installation of excess flow valves and manual service line shutoff valves for
Minnesota natural gas distribution systems. In addition, MN-PUC also provided a document, dated
March 18, 2019, to the Minnesota Department of Commerce, Division of Energy Resources, that
provides a description, a history, and the response from utilities related to the requirement for
excess flow valves.
Minnesota Department Public Safety/Office of Pipeline Safety Action
In response to the Minnehaha Academy accident and in reference to case number
145744454-1, the Minnesota Department of Public Safety issued (1) a Notice of Probable Violation
to CERC, relative to actions under 49 CFR 192.13(c) General, 49 CFR 192.703(a) General, and
49 CFR 191.9 Distribution System: Incident Report and issued (2) a Warning Letter to CERC,
relative to actions under 49 CFR 192.605(b) Procedural Manual for Operations, Maintenance, and
Emergencies and 49 CFR 192.727(d) Abandonment or Deactivation of Facilities.
9 CORRECTED COPY

<<<PAGE 10>>>

Minneapolis Natural Gas Explosion
Minnesota OSHA Action
Following the accident, Minnesota OSHA conducted an inspection of the accident site on
August 3, 2017, in which CenterPoint Energy, Inc., issued official correspondence stating, “… the
inspection resulted in no proposed citations.”5
Probable Cause
The National Transportation Safety Board determines that the probable cause of the natural
gas explosion at the Minnehaha Academy was the disassembling of piping upstream of a gas
service meter in the building by a pipefitting crew, resulting in the release of natural gas, which
subsequently ignited. Contributing to the accident was the lack of detailed documentation that
clearly established the scope of work to be performed.
For more details about this accident, visit www.ntsb.gov/investigations/dms.html, and
search for NTSB accident identification number DCA17MP007.
Date: January 2, 2020
The NTSB has authority to investigate and establish the facts, circumstances, and cause or probable
cause of a pipeline accident in which there is a fatality or substantial property damage. (Title 49
United States Code (USC) Section 1131 – General authority.)
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB
regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and
no adverse parties . . . and are not conducted for the purpose of determining the rights or liabilities
of any person.” Title 49 Code of Federal Regulations, Section 831.4. Assignment of fault or legal
liability is not relevant to the NTSB’s statutory mission to improve transportation safety by
investigating accidents and incidents and issuing safety recommendations. In addition, statutory
language prohibits the admission into evidence or use of any part of an NTSB report related to an
accident in a civil action for damages resulting from a matter mentioned in the report. (49 USC,
Section 1154[b].)
5 Reference correspondence Minnesota Department of Labor & Industry/Occupational Safety and Health Division
to CenterPoint Energy, Inc., dated Jan. 12, 2018, RE “OSHA Inspection 318101185 OSHI ID: O1457 05317,
Inspection Site 3100 W River Pkwy, Minneapolis, Minnesota, 55406”; for further information, see
https://www.dli.mn.gov/about-department/our-areas-service/minnesota-osha-compliance.
10 CORRECTED COPY

## Provenance

- Official: Yes
- Source: <https://www.ntsb.gov/investigations/Pages/DCA17MP007.aspx>
- Source ID: `ntsb-pipeline`
- SHA-256: `8ae07b823d47f0ae25312e19d0e76969c7315c9b5758208fd14ab0614870caf4`
- Retrieved: 2026-08-20T04:57:25.499Z
- Exported: 2026-08-22T16:32:41.060Z
- Document slug: `ntsb-case-dca17mp007`

### Source metadata

```json
{
  "recordKind": "ntsb_pipeline_investigation",
  "mkey": 95735,
  "ntsbNumber": "DCA17MP007",
  "completionStatus": "Completed",
  "caseClosed": true,
  "hasSafetyRecommendation": false,
  "eventType": "Accident",
  "accidentType": "Leak/explosion/fire",
  "operator": "CenterPoint Energy Minnesota Gas",
  "pipelineType": null,
  "location": {
    "city": "Minneapolis",
    "state": "MN",
    "country": "USA",
    "latitude": null,
    "longitude": null
  },
  "reportNumber": "PAB1903",
  "probableCause": "The National Transportation Safety Board determines that the probable cause of the natural gas explosion at the Minnehaha Academy was the disassembling of piping upstream of a gas service meter in the building by a pipefitting crew, resulting in the release of natural gas, which subsequently ignited. Contributing to the accident was the lack of detailed documentation that clearly established the scope of work to be performed.",
  "events": [
    {
      "eventNumber": 3,
      "sequenceNumber": 3,
      "eventCode": "160333",
      "tier1Number": "160",
      "tier1Name": "Initiating product flow",
      "tier2Number": "333",
      "tier2Name": "Pressure/flow control malf/failure",
      "isDefiningEvent": false
    },
    {
      "eventNumber": 4,
      "sequenceNumber": 6,
      "eventCode": "700170",
      "tier1Number": "700",
      "tier1Name": "Post-release",
      "tier2Number": "170",
      "tier2Name": "Explosion",
      "isDefiningEvent": false
    },
    {
      "eventNumber": 5,
      "sequenceNumber": 5,
      "eventCode": "700460",
      "tier1Number": "700",
      "tier1Name": "Post-release",
      "tier2Number": "460",
      "tier2Name": "Evacuation",
      "isDefiningEvent": false
    },
    {
      "eventNumber": 7,
      "sequenceNumber": 7,
      "eventCode": "700150",
      "tier1Number": "700",
      "tier1Name": "Post-release",
      "tier2Number": "150",
      "tier2Name": "Fire",
      "isDefiningEvent": false
    },
    {
      "eventNumber": 8,
      "sequenceNumber": 8,
      "eventCode": "600060",
      "tier1Number": "600",
      "tier1Name": "Emergency response",
      "tier2Number": "060",
      "tier2Name": "Emergency shutoff",
      "isDefiningEvent": false
    },
    {
      "eventNumber": 6,
      "sequenceNumber": 4,
      "eventCode": "401450",
      "tier1Number": "401",
      "tier1Name": "System operating, changing flow/pressure",
      "tier2Number": "450",
      "tier2Name": "Product leak/release",
      "isDefiningEvent": true
    },
    {
      "eventNumber": 2,
      "sequenceNumber": 2,
      "eventCode": "110040",
      "tier1Number": "110",
      "tier1Name": "System maintenance",
      "tier2Number": "040",
      "tier2Name": "Maintenance event",
      "isDefiningEvent": false
    },
    {
      "eventNumber": 1,
      "sequenceNumber": 1,
      "eventCode": "100020",
      "tier1Number": "100",
      "tier1Name": "System not operating",
      "tier2Number": "020",
      "tier2Name": "Servicing event",
      "isDefiningEvent": false
    }
  ],
  "findings": [
    {
      "findingNumber": 4,
      "sequenceNumber": 2,
      "findingCode": "04033073",
      "findingTier1Name": "Organizational ",
      "findingTier2Name": "Support/oversight/monitoring",
      "findingTier3Name": "Documentation/record keeping",
      "findingTier4Name": null,
      "findingModifierName": "Other institution/organization",
      "findingReportText": "Organizational  - Support/oversight/monitoring - Documentation/record keeping - Other institution/organization",
      "findingText": null,
      "inProbableCause": true
    },
    {
      "findingNumber": 5,
      "sequenceNumber": 3,
      "findingCode": "03014081",
      "findingTier1Name": "Environment/Infrastructure",
      "findingTier2Name": "Operating environment/control system",
      "findingTier3Name": "Product control system",
      "findingTier4Name": null,
      "findingModifierName": "Effect on equipment",
      "findingReportText": "Environment/Infrastructure - Operating environment/control system - Product control system - Effect on equipment",
      "findingText": null,
      "inProbableCause": false
    },
    {
      "findingNumber": 1,
      "sequenceNumber": 1,
      "findingCode": "02041539",
      "findingTier1Name": "Personnel",
      "findingTier2Name": "Action/decision",
      "findingTier3Name": "Information processing/decision making",
      "findingTier4Name": null,
      "findingModifierName": "Other company personnel",
      "findingReportText": "Personnel - Action/decision - Information processing/decision making - Other company personnel",
      "findingText": null,
      "inProbableCause": true
    }
  ],
  "caveat": "Official NTSB investigation data. NTSB findings determine probable cause and make safety recommendations; they do not adjudicate civil liability or regulatory violations.",
  "investigationPageAvailable": true,
  "investigationPageUrl": "https://www.ntsb.gov/investigations/Pages/DCA17MP007.aspx",
  "docketUrl": "https://data.ntsb.gov/Docket/?NTSBNumber=DCA17MP007",
  "reportArtifacts": [
    {
      "id": "ntsb-report-pab1903",
      "title": "PAB-19-03",
      "url": "https://www.ntsb.gov/investigations/AccidentReports/Reports/PAB1903.pdf",
      "pageCount": 10,
      "pdfArtifactPath": "data/sources/ntsb-reports/artifacts/reports/ntsb-report-pab1903.pdf",
      "pdfArtifactSha256": "435ea7fdc2dfd1dbabbba5f354dac2724b45ecc8b093db4f9a2f8c93e7e31b78",
      "extractedTextPath": "data/sources/ntsb-reports/artifacts/reports/ntsb-report-pab1903.txt",
      "extractedTextSha256": "694ad92555645ee3438b63945febd80087a401b88df2f0e02eaca0f587269747",
      "extractionVersion": 2
    }
  ],
  "jurisdiction": "US",
  "operatorName": "CenterPoint Energy Minnesota Gas",
  "region": "MN"
}
```
