{"operation":"document","citation":"DCA17FP003","title":"Third-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System","source_type":"incident","agency":"National Transportation Safety Board","status":"current","official":true,"published_on":"2021-05-18","effective_on":"2016-11-16","summary":"Accident. in Canton, IL, USA. on 2016-11-16. Ameren. Leak/explosion/fire","machine_formats":{"json":"https://regulus.evalyn.ai/document/ntsb-case-dca17fp003.json","markdown":"https://regulus.evalyn.ai/document/ntsb-case-dca17fp003.md"},"app_url":"https://regulus.evalyn.ai/document/ntsb-case-dca17fp003","source_url":"https://www.ntsb.gov/investigations/Pages/DCA17FP003.aspx","body":"NTSB investigation DCA17FP003.\n\nEvent Type: Accident\n\nEvent Date: 2016-11-16\n\nEvent City: Canton\n\nEvent State Or Region: IL\n\nEvent Country: USA\n\nPipeline Operator: Ameren\n\nAccident Type: Leak/explosion/fire\n\nCompletion Status: Completed\n\nReport Number: PAB1802\n\nReport Date: 2018-12-03\n\nProbable cause: The National Transportation Safety Board determines that the probable cause of the natural gas release and subsequent explosion was third party damage from Sure Shot’s directional drilling to install underground fiber optic conduit. Contributing to the pipeline damage was Sure Shot’s decision not to excavate at the utility crossing to visually inspect the work, while in progress, until clear of the underground utilities, as required by Illinois law. Contributing to the severity of the accident was the failure of Sure Shot and Ameren to evacuate the area.\n\nTier1Name: Emergency response\n\nTier2Name: Evacuation\n\nTier1Name: Emergency response\n\nTier2Name: Emergency shutoff\n\nTier1Name: Emergency response\n\nTier2Name: Explosion\n\nTier1Name: System shutdown\n\nTier2Name: Fire (post-release)\n\nTier1Name: System operating\n\nTier2Name: Product leak/release\n\nTier1Name: System operating\n\nTier2Name: External/third-party damage\n\nFinding Tier1Name: Organizational\n\nFinding Tier2Name: Support/oversight/monitoring\n\nFinding Tier3Name: Oversight\n\nFinding Modifier Name: Other institution/organization\n\nFinding Report Text: Organizational - Support/oversight/monitoring - Oversight - Other institution/organization\n\nFinding Tier1Name: Environment/Infrastructure\n\nFinding Tier2Name: Task environment\n\nFinding Tier3Name: Physical workspace\n\nFinding Modifier Name: Decision related to condition\n\nFinding Report Text: Environment/Infrastructure - Task environment - Physical workspace - Decision related to condition\n\nFinding Tier1Name: Pipeline\n\nFinding Tier2Name: Pipeline handling/service\n\nFinding Tier3Name: Maintenance/inspection\n\nFinding Modifier Name: Inadequate inspection\n\nFinding Report Text: Pipeline - Pipeline handling/service - Maintenance/inspection - Inadequate inspection\n\nFinding Tier1Name: Personnel\n\nFinding Tier2Name: Action/decision\n\nFinding Tier3Name: Information processing/decision making\n\nFinding Modifier Name: Equipment/vehicle operator\n\nFinding Report Text: Personnel - Action/decision - Information processing/decision making - Equipment/vehicle operator\n\nFinding Tier1Name: Organizational\n\nFinding Tier2Name: Management\n\nFinding Tier3Name: Policy/procedure\n\nFinding Modifier Name: Other institution/organization\n\nFinding Report Text: Organizational - Management - Policy/procedure - Other institution/organization\n\nOfficial NTSB investigation data. NTSB findings determine probable cause and make safety recommendations; they do not adjudicate civil liability or regulatory violations.\n\nWhat Happened\nOn November 16, 2016, about 5:44 p.m. central standard time, a natural gas-fueled explosion occurred at a two-level commercial building located at 45 East Side Square in Canton, Illinois. One Ameren employee was killed and 11 people were injured, including two Ameren employees.\n\nWhat We Found\nWe determined that the probable cause of the natural gas release and subsequent explosion was third party damage from Sure Shot’s directional drilling to install underground fiber optic conduit. Contributing to the pipeline damage was Sure Shot’s decision not to excavate at the utility crossing to visually inspect the work, while in progress, until clear of the underground utilities, as required by Illinois law. Contributing to the severity of the accident was the failure of Sure Shot and Ameren to evacuate the area.\n\nPAB-18-02\n<<<PAGE 1>>>\n\nNational Transportation Safety Board\nPipeline Accident Brief\nThird-party Damage by Sure Shot Communications\nto Ameren Natural Gas Distribution System\nCanton, Illinois\nThe Accident\nOn November 16, 2016, about 5:44 p.m. central standard time, a natural gas-fueled\nexplosion occurred at a two-level commercial building located at 45 East Side Square in Canton,\nIllinois. One Ameren employee was killed and 11 people were injured, including two Ameren\nemployees.\nPrior to the accident, Sure Shot Communications LLC (Sure Shot), a contractor for\nMid Century Communications (Mid Century), a telephone and fiber optics cooperative, was\nperforming directional drilling adjacent to the building to install conduit for fiber optic cable.1\nAbout 9:00 a.m., the Sure Shot crew began performing multiple drills at various locations on the\nblock. At 3:58 p.m., the contractor reported to the Joint Utility Locating Information for Excavators\n(JULIE), the one-call message handling and delivery service for identifying underground utilities,\nthat a marked gas line had been damaged. The damage occurred while crews were pulling the drill\nrod back to the drilling rig after a directional drilling operation under the sidewalk along North\nFirst Street.\nAt 4:06 p.m., Ameren Illinois (Ameren), the owner and operator of the gas line, received a\ndamage report from Sure Shot and dispatched field technicians to evaluate the situation. About\n7 minutes later, the first Ameren responder arrived at the scene; three other Ameren technicians\narrived shortly thereafter. The lead Ameren responder contacted his supervisor to confirm the\npipeline had been struck and to request excavation equipment to uncover the service line. A\nbackhoe excavator arrived at 4:41p.m. and Ameren technicians began to isolate the leak.\nAt 4:48 p.m., nearby customers called the Ameren Customer Contact Center to report\nnatural gas odors both indoors and outdoors. According to Ameren, these customers were given\nsafety instructions and told to leave their buildings if an odor was detected.\n2 By 5:37 p.m., Ameren\ntechnicians shut off the natural gas flow to the service line by squeezing off the pipeline. At 5:44\np.m., the Opera House Annex behind the Opera House Professional Center exploded, killing one\nand injuring 11 who were impacted by debris from the blast. (See figures 1 and 2.)\n1 Directional drilling is a trenchless pipe or conduit installation technique that involves drilling into the soil to\ncreate a horizontal bore or pathway for the pipe or conduit.\n2 Ameren provided verbal instructions as written in their Customer Contact Center Emergency Plan Procedures,\nsubsection 4.G and 4.H.\nNTSB/PAB-18/02\n\n<<<PAGE 2>>>\n\nThird-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System\nFigure 1. A Google Earth image of the back of the Opera House Professional Center and the\ntwo-level Opera House Annex prior to the accident.\nFigure 2. Photograph of the accident site and debris from the Opera House Annex. (Courtesy of\nCanton Police Department.)\n2\n\n<<<PAGE 3>>>\n\nThird-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System\nThe Pipeline System\nThe damaged natural gas service line was a 1-inch polyethylene line connected to a 2-inch\ngas main located about 6 feet east of the west curb line (inside the roadway) of North First Street.\nThe service line was installed on December 6, 2012, and was 32 feet long.3 The natural gas service\nwas operating at 30 pounds per square inch gauge (psig) with a maximum allowable operating\npressure of 60 psig.\nSure Shot Communications LLC\nSure Shot had previously performed fiber optic conduit installation for Mid Century;\nhowever, there was no written contract between the companies for the work performed on the day\nof the accident or past work. Additionally, Sure Shot did not have either a written project plan or\nan emergency response plans for the work. The company also did not have qualification and\ntraining records for the employees performing directional drilling. The day of the accident was the\nfirst field work day for the employee-in-charge (crew leader) of the directional drilling crew. Sure\nShot positioned directional drilling equipment at the corner of East Chestnut and North First Street.\nThe crew drilled southward, under the sidewalk, to a utility handhole located about 1 foot past the\nservice line to the extension of the Opera House Professional Center.4 Figure 3 shows the location\nof the drilling rig in relation to the Opera House Professional Center and depicts the horizontal\ndrill path and the location where the gas service line was struck.\n3 Prior to the installation of this gas main line and service in 2012, the Opera House Annex was serviced by a\nbranch line off the service line to the Opera House Professional Center at 45 East Side Square.\n4 A handhole is an opening created on the face of an underground concrete junction box used for the routing and\ntermination of below grade cables/wires.\n3\n\n<<<PAGE 4>>>\n\nThird-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System\nFigure 3. An illustration of the drill path and the location where the gas service line was struck.\nThe location of the natural gas service line damage was underneath the concrete sidewalk\nadjacent to the destroyed structure. Sure Shot did not excavate the utility crossing location before\nstarting the drilling work, as required by Illinois statute.5 According to Illinois law, during\ndirectional drilling, each location where the drill path crosses underground, utilities must be\nexcavated using methods such as hand or vacuum excavation. The excavator must visually inspect\nthe work, while in progress, until clear of the underground utilities.\nSection 4(a) and (b) of 220 Illinois Compiled Statutes (ILCS) 50, Illinois Underground\nUtility Facilities Damage Prevention Act, states: Every person who engages in nonemergency\nexcavation or demolition shall:\n(a) take reasonable action to inform himself of the location of any underground\nutility facilities in and near the area for which such operation is to be conducted;\n(b) plan the excavation or demolition to avoid or minimize interference with\nunderground utility facilities within the tolerance zone by utilizing such precautions\n5 The Illinois Commerce Commission’s Natural Gas Pipeline Safety section is charged with inspection and\nenforcement activities applicable to intrastate natural gas transmission, distribution and gathering pipeline facilities to\nassure compliance with all federal and state safety rules and regulations pertaining to the design, construction,\noperation, and maintenance of those facilities (see https://www.icc.illinois.gov/pipelinesafety/ accessed October 29,\n2018).\n4\n\n<<<PAGE 5>>>\n\nThird-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System\nthat include, but are not limited to, hand excavation, vacuum excavation methods,\nand visually inspecting the excavation while in progress until clear of the existing\nmarked facility.\nThe crew leader told National Transportation Safety Board (NTSB) investigators that the\nowner of Sure Shot instructed him not to excavate under the concrete slab to avoid replacing the\nrelatively new concrete sidewalk.6\nThe crew leader was concerned about the failure to expose the gas line; however, he\nthought it would be adequate since the crew was drilling 30 inches underground or below the depth\nof the natural gas line that he believed was buried 18 inches.\n7 (See figure 5.)\nFigure 5. Image showing the damaged yellow service line intersected by the orange fiber optic\ncable conduit.\nHe told investigators that he believed the drill crossed the natural gas line without incident\nand that the strike occurred when the drill machine operator was pulling the drill rod back to the\ndrill rig.8 He was certain that he would have smelled natural gas in the handhole if the drill had\n6 Interview summary of Sure Shot owner located in NTSB Docket DCA17FP003.\n7 The bore diameter was 6 inches.\n8 The pullback of the drill rod was described as a dead pull, meaning the drill is neither rotating nor spinning on\nthe way back to the drill rig.\n5\n\n<<<PAGE 6>>>\n\nThird-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System\nstruck the gas line when pushing the drill rod to the vault since it was only a foot away and he had\nhis face in the vault.\nAfter striking the gas line, the crew leader described hearing, smelling, and seeing the\nleaking gas moving rocks and soil in the handhole. He called JULIE to report the accident and also\ncontacted Ameren after he spoke with a representative from Mid Century. He did not contact 911.\nHe told NTSB investigators that he believed JULIE would make the 911 notification.9\nAmeren provided the crew leader with safety instructions to block off the street and to\nevacuate nearby buildings. The Sure Shot crew shut off their equipment and blocked off the street:\nthe crew leader spoke to people leaving the nearby buildings. Some of these individuals told him\nthey smelled gas and he instructed them to leave the building. Additionally, he attempted to\nevacuate the Opera House Annex by knocking on the door, but no one answered. He awaited the\narrival of Ameren response personnel.\nMid Century Communications\nOn the day of the accident, a Mid Century representative was at the excavation site all day;\nhowever, he told NTSB investigators he was not responsible for overseeing work by Sure Shot\nemployees. His role was to answer technical questions from either Sure Shot or potential\ncustomers. He stated that he spent most of his day sitting in his vehicle.\n10\nLocal Emergency Response Notifications\nThe Sure Shot employees, the Ameren field technicians, and Ameren dispatch center\npersonnel called did not call 911 to report the gas leak prior to the explosion. In response to a one\ncall enforcement information request from the Illinois Commerce Commission, the owner of Sure\nShot stated that the company did not contact 911 since JULIE usually dispatches the fire\ndepartment when gas leaks are reported. However, he affirmed on the same form that he is aware\nthat Section 7 of Illinois Underground Utility Facilities Damage Prevention Act requires that “[i]n\nthe event of any damage to any underground utility facility that results in the escape of any\nflammable, toxic, or corrosive gas or liquid, the person responsible for the excavation or\ndemolition shall call 911 and notify authorities of the damage.” He also affirmed that the same\nsection of the Act requires the person responsible to immediately notify both the affected utility\nand JULIE.\nAmeren employees responding to the damage report were on scene for about 1.5 hours\nbefore the explosion. The employees recorded gas readings were taken from the outside perimeter\n9 The Horizontal Directional Drilling (HDD) industry at large must follow the appropriate state one call digging\nand Occupational Safety and Health Administration laws, however; in the state of Illinois, there are no training or\ncertification requirements for HDD contractors who work on water, telecommunications, and other utilities with HDD\nequipment. Federal rules do exist for contractors performing work on gas utilities whereby HDD operators must\ncomply and meet the requirements under the Operator Qualification rules in the PHMSA Pipeline Safety Regulations.\n10 Interview summary of Mid Century employee located in NTSB Docket DCA17FP003.\n6\n\n<<<PAGE 7>>>\n\nThird-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System\nof the Opera House Professional Center building; however, they did not take any readings from\ninside the building despite Ameren having received both indoor and outdoor odor complaints.\nService Line Damage\nAn Ameren utility crew excavated and visually examined the damaged service line at the\naccident scene. The top of the 1-inch polyethylene line showed clear damage as a result of being\nstruck by drilling equipment. The damage to the service line from the directional drilling is shown\nin figure 6.\nFigure 6. Damaged service line to the exploded building from two different angles.\nProbable Cause\nThe National Transportation Safety Board determines that the probable cause of the natural\ngas release and subsequent explosion was third party damage from Sure Shot’s directional drilling\nto install underground fiber optic conduit. Contributing to the pipeline damage was Sure Shot’s\ndecision not to excavate at the utility crossing to visually inspect the work, while in progress, until\nclear of the underground utilities, as required by Illinois law. Contributing to the severity of the\naccident was the failure of Sure Shot and Ameren to evacuate the area.\nFor more details about this accident, visit www.ntsb.gov/investigations/dms.html and search for\nNTSB accident ID DCA17FP003.\nIssued: December 3, 2018\n7\n\n<<<PAGE 8>>>\n\nThird-party Damage by Sure Shot Communications to Ameren Natural Gas Distribution System\nThe NTSB has authority to investigate and establish the facts, circumstances, and cause or probable\ncause of a pipeline accident in which there is a fatality, substantial property damage, or significant\ninjury to the environment. (49 US Code § 1131 - General authority)\nThe NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB\nregulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no\nadverse parties . . . and are not conducted for the purpose of determining the rights or liabilities of any\nperson.” Title 49 Code of Federal Regulations, Section 831.4. Assignment of fault or legal liability is\nnot relevant to the NTSB’s statutory mission to improve transportation safety by investigating\naccidents and incidents and issuing safety recommendations. In addition, statutory language prohibits\nthe admission into evidence or use of any part of an NTSB report related to an accident in a civil action\nfor damages resulting from a matter mentioned in the report. 49 USC 1154(b).\n8","truncated":false,"body_characters":17737}