NTSB Safety Recommendation P-15-038

NTSB safety recommendation P-15-038.

TO THE PUBLIC SERVICE COMMISSION OF THE STATE OF NEW YORK: Revise your gas utility operator program to ensure all elements of the regulations are included in the 5-year audit plan.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2015-06-29

Adopted Date: 2015-06-09

Overall Date Closed: 2015-11-02

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, Public Service Commission

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2015-11-02

Addressee Acronym: NYSPSC

Addressee Organization Type: S-State Government

Communication Date: 2015-09-28

Communication Type: Official Correspondence

Communication Contents: -From Audrey Zibelman, Chair: The New York State Department of Public Service (NYSDPS) appreciates the National Transportation Safety Board’s (NTSB) guidance and assistance offered during the investigation of the March 12, 2014 East Harlem, New York incident as well as the opportunity to contribute our expertise to the NTSB’s investigation. Ensuring gas safety is of highest priority for the NYSDPS and the Public Service Commission. We are committed to taking lessons learned from East Harlem to further assure gas safety in New York. The NYSDPS Pipeline Safety program is strong and we continue to look for strengthening opportunities to be sure that New York’s pipeline system remains safe and reliable. The NYSDPS agrees with the NTSB that we must review all elements of the state regulations in our 5-year audit plans. In fact, since shortly after pipeline personnel were required to be qualified in compliance with the operator qualification (OQ) rule (49 CFR §192.809) in 2002, the NYSDPS has regularly conducted field evaluations of operator qualification program implementation during the field audit portion of NYSDPS operations and maintenance audits. Moreover, the NYSDPS Pipeline Safety section has conducted record and field audits of all operations and maintenance activities as part of our 5-year audit plan. This includes determining whether a utility’s internal procedures include all operations and maintenance activities mandated in existing safety regulations, whether the utility is following its procedures, and whether the utility performs at the level required by all operations and maintenance regulations, all of which mirror, and sometimes go beyond, the federal requirements. As part of these audits and at site visits, NYSDPS Gas Safety Staff routinely check the qualifications of utility personnel and contractors to confirm compliance with the utility’s operator qualification program. However, going forward, the changes we are making in response to the NTSB recommendation will ensure that this review is more routinized and includes an evaluation of training (if applicable) and testing for the covered task. Therefore, in light of the NTSB’s Recommendation P-15-38 in its June 19, 2015, East Harlem Report, and as part of our continuous improvement process, the NYSDPS has formally changed its 5-year audit procedures to clarify that evaluations of operator qualification programs (OQ), including audits of written operation qualification programs and procedures, covered task training, the manner in which operators qualify an individual for a covered task, and on-site OQ field evaluations (Protocol 9) will occur for each pipeline operator at intervals that do not exceed five years. This is consistent with the Pipeline and Hazardous Materials Safety Administration’s (PHMSA) “Guidelines for States Participating in the Pipeline Safety Program,” the details of which we have always adopted in our practices. To be clear, the NYSDPS will audit each of the items listed in the revised 5-year audit plan (including the OQ items listed above) in our 5-year audit cycle; when we audit those items, as we do with all items audited, we randomly select documents from each. We believe these changes address NTSB recommendation P-15-38. Of note, over the last several years, the NYSDPS has revised NYSDPS forms to more thoroughly document compliance with operations and maintenance audits; we have added steps to the audit process to more clearly document that the Department reviewed the pipeline operator’s procedures during the audit process; and we have revised the process to review emergency plans so that Staff can determine compliance with emergency plan requirements and ensure that the plans incorporate PHMSA guidance (advisory bulletins, etc.) and industry best practices. Finally, the New York State Public Service Commission has adopted rate case performance metrics that hold local distribution companies accountable to performance levels in the areas of emergency response, damage prevention, leak management, and violation reduction. These metrics include negative rate adjustments if certain acceptable performance thresholds are not met or exceeded to align utility management focus with these important areas. The NYSDPS is committed to continually improving gas safety in New York State, and we look forward to working with the NTSB on these very important issues.

Addressee Acronym: NYSPSC

Addressee Organization Type: S-State Government

Communication Date: 2015-11-02

Communication Type: Official Correspondence

Communication Contents: We understand that, shortly after pipeline personnel were required to meet the operator qualification (OQ) rule in 2002, (Title 49 Code of Federal Regulations 192.809), the New York State Department of Public Service (NYSDPS) began conducting regularly scheduled field evaluations of operator qualification program implementation during the field audit portion of NYSDPS operations and maintenance audits. Further, NYSDPS formally changed its 5 year audit procedures to clarify that evaluations of OQ, which include audits of written operation qualification programs and procedures, cover task training. We note that the department will conduct on-site OQ field evaluations, Protocol 9, for each pipeline operator at least once every 5 years. In addition, NYSDPS will audit each of the items listed in the revised 5 year audit plan in its 5-year audit cycle and, during the audits, will randomly select documents from each item. These practices are consistent with the Pipeline and Hazardous Materials Safety Administration’s Guidelines for States Participating in the Pipeline Safety Program and satisfy Safety Recommendation P-15-38, which is classified CLOSED—ACCEPTABLE ACTION. Thank you for your assistance and for your commitment to pipeline safety.