NTSB Safety Recommendation P-15-033

NTSB safety recommendation P-15-033.

TO THE CITY OF NEW YORK: Implement a written program or procedure to ensure the integrity of your sewer lines, repair breaches in a timely manner, and coordinate with other agencies to identify and address potential soil disruption and voids.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2015-06-29

Adopted Date: 2015-06-09

Overall Date Closed: 2016-05-03

Synopsis: On March 12, 2014, about 9:30 a.m. eastern daylight time, two adjacent multiuse five-story buildings were destroyed by a natural gas-fueled explosion and resulting fire. The buildings were situated on the west side of Park Avenue between East 116th Street and East117th Street in the East Harlem district of the Borough of Manhattan in New York City. The violent explosion damaged buildings on the east and west sides of Park Avenue and along East116th and East 117th Streets. The Metro-North Railroad suspended rail service for about 71/2 hours on the elevated railway along Park Avenue because of debris from the explosion on the track. Eight people died, more than 50 people were injured, and more than 100 families were displaced from their homes as a result of this accident. The cost to Consolidated Edison Company of New York, Inc. (ConEdison), of equipment damages, emergency response activities, remediation, and replacement exceeded $1.9 million.

Probable Cause: The National Transportation Safety Board determines that the probable cause of the accident was (1) the failure of the defective fusion joint at the service tee, installed by Consolidated Edison Company of New York, Inc., in 2011, that allowed natural gas to leak from the gas main and migrate into the building where it ignited and (2) a breach in the sewer line that went unrepaired by the New York City Department of Environmental Protection since at least 2006 that allowed groundwater and soil to flow into the sewer, resulting in a loss of support for the gas main, which caused the line to sag and overstressed the defective fusion joint.

Ntsbnumber: DCA14MP002

Report Number: PAR-15-01

Addressee Name: State of New York, City of New York

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2016-05-03

Addressee Acronym: NYC

Addressee Organization Type: L-Local Government

Communication Date: 2015-09-25

Communication Type: Official Correspondence

Communication Contents: -From William H. Goldstein, Senior Advisor to the Mayor for Recovery, Resiliency, and Infrastructure: The Office of the Mayor for the City of New York hereby responds to your June 29, 2015 letter (P-15-33) which references the June 9, 2015 report that the NTSB adopted concerning the March 12, 2014 natural gas-fueled explosion that occurred in the East Harlem district of the Borough of Manhattan, New York City. We thank the NTSB for its diligent efforts regarding its investigation of this accident and the cooperative and professional manner in which the investigation was conducted. The safety of our fellow New Yorkers is our first and foremost concern. Accordingly, the City of New York has closely analyzed the single safety recommendation the NTSB issued requesting that the City "Implement a written program or procedure to ensure the integrity of your sewer lines, repair breaches in a timely manner, and coordinate with other agencies to identify and address potential soil disruption and voids." The City is actively working on addressing the issues raised, and a response is under development. As the recommendation entails the coordination of multiple City agencies and addresses complicated infrastructure issues, the City needs additional time to work on implementing the recommendation, and will provide a further response within 6 months, and no later than March 23, 2016.

Addressee Acronym: NYC

Addressee Organization Type: L-Local Government

Communication Date: 2016-03-23

Communication Type: Official Correspondence

Communication Contents: -From Anthony Shorris, First Deputy Mayor: The New York City Department of Environmental Protection (DEP) maintains approximately 15,000 miles of water and sewer infrastructure, nearly 150,000 catch basins, 110,000 fire hydrants and hundreds of thousands of other components of an integrated sewer and water system serving the City of New York. The agency manages 14 wastewater treatment plants, nearly 100 individual pump stations, 2000 square miles of watershed, 19 upstate reservoirs and 3 controlled lakes. Every day the agency provides nearly 9 million New York City and State residents with nearly 1 billion gallons of fresh drinking water and treats 1.3 billion gallons of wastewater. The Bureau of Water and Sewer Operations (BWSO) within DEP comprises a staff of 1250 persons and an operating budget of approximately $180 million. These resources are devoted, as a core responsibility, to maintaining the quality and integrity of the underground water and sewer network of New York City. BWSO responds annually to tens of thousands of customer service requests related to potential water and sewer assets and performs tens of thousands of operational maintenance and repair activities related to maintaining a state of good repair of the agency's underground assets. The agency is widely regarded as among the largest and best managed water and wastewater utilities in the world. DEP has routinely performed tiered investigations and repairs of various conditions that may arise including, where necessary, capital repair or replacement. In response to the NTSB's recommendation, in order to make operations even more effective, DEP conducted a comprehensive review of procedures related to the management of this work in order to further expedite and prioritize repair of defects and ensure sewer line integrity. This review included assessments of the volume of work and existing processes, and the recognition that more focused attention was needed overall, which led BWSO to re-organize its management structure by creating the Contracts, Repairs, and Maintenance Directorate. This directorate is responsible for the overall management and coordination of sewer investigations and repairs referred by Field Operations. Further, BWSO codified prior work flows and implemented written guidelines governing condition assessment and prioritization ("Process Guidelines for Condition Assessment/Prioritization Process"), effective September 15, 2015. These guidelines were distributed to relevant field operators and management personnel and have been integrated into the bureau's operations. These guidelines provide an outline of responsibilities for the sewer break work order and repair process, and governs the division of responsibility between and among three BWSO groups: (1) Field Operations, which staff includes first responders charged with the initial investigation of all complaints and making the initial determination as to whether a condition requires emergency repair, (2) Capacity, Management, Operations and Management (CMOM), which is responsible for a more detailed condition analysis and investigation of non-emergency repair, with the ability to escalate if it is identified as an emergency condition, and (3) Emergency Construction, which is responsible for repairing emergency conditions. Under these guidelines, sewer conditions are evaluated using the Pipeline Assessment and Certification Program methodology, 1 recurring non-emergency conditions are targeted for repair, and repairs are triaged according to level of risk and condition of the asset. As part of these process improvements, DEP has consolidated the flow of information and reporting for these three groups into its primary operational system. This will allow BWSO to coordinate work, create a record of, and internal accountability for, risk assessment and prioritization decisions, and establish metrics and goals for performing non-emergency repairs. Together, the reorganization, codification of guidelines, and clear accountability should make DEP's well-regarded work even more effective and ensure that sewer defects are identified, assessed, and repaired in a timely manner. The City has also introduced new procedures to enhance coordination between DEP, the New York City Department of Transportation (DOT), and private utilities to address and respond to street defects suggesting the possibility of soil disruptions or voids. Following the March 12, 2014 East Harlem gas explosion, in May of the same year, DOT modified its procedure for identifying, tracking, reporting, and referring street defects, such as cave-ins and depressions. Previously, once DOT was notified of such a condition (primarily via 311, the City's call-in number for government information and non-emergency services), in accordance with New York City Department of Transportation Highway Rules 34 RCNY §2-02, DOT inspected the location and referred the defect to the party responsible for repair by issuing a Corrective Action Request (CAR). As a result of the May 2014 modification, copies of CARs issued to DEP for street defects are now also sent to gas utilities in the vicinity of the street defect. Additionally, DOT is also reviewing historical CAR data to identify locations of recurring conditions for re-inspection to determine if action or referral is needed. This information will be shared with the utilities. Finally, in response to the NTSB's recommendation, the City has formed a working group comprised of DOT, DEP, Con Edison, and National Grid who meet on a regular basis to look at both the historical and new data to identify and review locations with reoccurring cave-ins or depressions for evaluation and potential remediation.

Addressee Acronym: NYC

Addressee Organization Type: L-Local Government

Communication Date: 2015-11-02

Communication Type: Official Correspondence

Communication Contents: Mr. Goldstein reports that the city is coordinating multiple agencies to address this issue, and promises a further response no later than March 23, 2016. We look forward to receiving a comprehensive update on your plans as soon as possible. Pending our receipt of your substantive reply, Safety Recommendation remains classified OPEN—AWAIT RESPONSE.

Addressee Acronym: NYC

Addressee Organization Type: L-Local Government

Communication Date: 2016-05-03

Communication Type: Official Correspondence

Communication Contents: We understand that the New York City Department of Environmental Protection (DEP) reviewed procedures related to the management of integrated sewer and water systems to further expedite and prioritize the repair of defects and to ensure sewer line integrity. The DEP assessed the volume of work and existing processes and determined that more attention was needed overall, which led the Bureau of Water and Sewer Operations (BWSO) to reorganize its management structure by creating the Contracts, Repairs, and Maintenance Directorate. We note that, on September 15, 2015, the BWSO codified prior work flows and implemented written guidelines in Process Guidelines for Condition Assessment/Prioritization Process, delineating responsibilities for the sewer break work order and repair process and governing the division of responsibility among three BWSO groups: (1) Field Operations, which includes first responders charged with the initial investigation of all complaints and with making the initial determination about whether a condition requires emergency repair; (2) Capacity, Management, Operations and Management (CMOM), which conducts a more detailed condition analysis and investigation of non-emergency repair and determines which of these repairs need to be addressed as emergencies; and (3) Emergency Construction, which is responsible for repairing emergency conditions. We further note that the guidelines have been distributed to relevant field operators and management personnel and have been integrated into the bureau’s operations. We understand that, in May 2014, the New York City Department of Transportation (DOT) modified its procedure for identifying, tracking, reporting, and referring street defects, such as cave-ins and depressions. Previously, when notified of such a condition, the DOT inspected the location and referred the defect to the party responsible for repair by issuing a Corrective Action Request (CAR). As a result of the May 2014 modification, copies of CARs issued to the DEP for street defects are now also sent to gas utilities in the vicinity of the problem. In addition, the DOT is reviewing historical CAR data to identify locations of recurring conditions for reinspection to determine whether action or referral is needed. This information will also be shared with the utilities. Finally, we are pleased to learn that you formed a working group comprising representatives of the DOT, DEP, Con Edison, and National Grid, who meet on a regular basis to examine both the historical and new data to identify and review locations with reoccurring cave ins or depressions for evaluation and potential remediation. These actions satisfy the intent of Safety Recommendation P-15-33, which is classified CLOSED—ACCEPTABLE ACTION.