NTSB Safety Recommendation P-18-001

NTSB safety recommendation P-18-001.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Work with state pipeline regulators to incorporate into their inspection programs, a review to ensure that gas distribution pipeline operators are using best practices recommended by the manufacturer in their distribution integrity management programs, including using the specified tools and methods, to correctly install PermaLock mechanical tapping tee assemblies.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 2018-06-25

Adopted Date: 2018-06-15

Overall Date Closed: 2019-07-24

Synopsis: The National Transportation Safety Board (NTSB) is providing the following information to urge the Pipeline and Hazardous Materials Safety Administration (PHMSA) and Honeywell to take action on safety recommendations intended to prevent the incorrect installation of PermaLock mechanical tapping tee assemblies in gas distribution systems. These recommendations are derived from our ongoing investigation of a fatal accident involving a natural gas explosion and fire in Millersville, Pennsylvania. The NTSB is issuing two recommendations to PHMSA and two recommendations to Honeywell.

Probable Cause: The National Transportation Safety Board determines that the probable cause of the natural gas explosion at 206 Springdale Lane was an improperly installed mechanical tapping tee that leaked and allowed gas to migrate into the house where it ignited.

Keywords: Hazmat

Ntsbnumber: DCA17FP006

Report Number: PSR-18-01

Addressee Name: PHMSA

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2019-07-24

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2018-06-25

Communication Type: Transmittal Letter

Communication Contents: On June 18, 2018, the National Transportation Safety Board (NTSB) adopted its safety recommendation report Installation of PermaLock Mechanical Tapping Tee Assemblies, PSR-18/01. This report is based on our ongoing investigation of a fatal accident involving a natural gas explosion and fire in Millersville, Pennsylvania, on July 2, 2017. The details of the ongoing investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Among the Safety Recommendations are two recommendations issued to the Pipeline and Hazardous Materials Safety Administration, which can be found on page 9 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 10 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2019-02-04

Communication Type: Official Correspondence

Communication Contents: We note that you plan to take the following actions: 1) By August 31, 2019, you will modify supporting information in the DIMP Inspection Assistant (IA) to specifically reference the issues with installing PermaLock mechanical tapping tee assemblies, notify states of the updated questions after the IA revisions are published, and post the updated forms on your website. 2) To reach state pipeline regulators, by August 31, 2019, you will update your gas state program evaluation questionnaire to include an assessment of whether state inspectors have guidance on reviewing operators’ use of manufacturer recommended best practices in their operations and maintenance manuals and in their DIMPs. This guidance should include the use of specified tools and methods to correctly install PermaLock mechanical tapping tee assemblies. You are currently communicating with the National Association of Pipeline Safety Representatives regarding these modifications. 3) By January 31, 2019, you will work with the American Public Gas Association (APGA) Security and Integrity Foundation (SIF) to include a set of questions regarding PermaLock mechanical tapping tee assemblies in the APGA SIF’s “Simple, Handy, Risk-Based Integrity Management Plan” online tool for operators of natural gas distribution systems. The APGA has forwarded our report and recommendations about PermaLock mechanical tapping tee assemblies to its members, informing them that the issues should be accounted for in an operator’s DIMP, and that the operator should ensure that best practices recommended by the manufacturer are incorporated into applicable procedures in their required operations and maintenance manuals. Pending completion of these actions, Safety Recommendation P-18-1 is classified OPEN--ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2019-07-24

Communication Type: Official Correspondence

Communication Contents: We note that you have completed the following actions: 1) Modified seven inspection questions in the DIMP Inspection Assistant (IA) involving gas distribution, master meter, and small liquefied petroleum integrity management to address the issues associated with the installation of PermaLock mechanical tapping tee assemblies, and you notified states of these changes by posting the revised IA question set on your website. 2) Cooperated with the American Public Gas Association (APGA) Security and Integrity Foundation (SIF) to add a set of questions regarding PermaLock mechanical tapping tee assemblies to the APGA SIF’s “Simple, Handy, Risk-Based Integrity Management Plan” online tool for operators. APGA SIF also published PowerPoint slides and a webinar of the revised management plan that discuss issues associated with PermaLock installations. 3) Revised question C-17 in the Pipeline Safety Gas State Program Evaluation Evaluator Guidance to include a discussion of whether the state provided inspection guidance for inspectors to ensure that gas distribution pipeline operators are using best practices recommended by the manufacturers of PermaLock mechanical tapping tees in their operations and maintenance manuals and distribution integrity management programs. These best practices include using the specified tools and methods to correctly install PermaLock mechanical tapping tee assemblies. The actions you have described satisfy Safety Recommendation P-18-1, which is classified CLOSED--ACCEPTABLE ACTION.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2020-01-23

Communication Type: Official Correspondence

Communication Contents: In our July 24, 2019, response to your June 14, 2019, letter, we classified Safety Recommendation P-18-1 CLOSED--ACCEPTABLE ACTION.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2018-08-31

Communication Type: Official Correspondence

Communication Contents: -From Howard L. Elliott, Administrator: We concur. By August 31, 2019, PHMSA proposes to modify supporting information in the Distribution Integrity Management Program (DIMP) Inspection Assistant (IA) to specifically reference the issues with installation of PermaLock mechanical tapping tee assemblies. The changes to the DIMP IA will help federal and state users ensure that gas distribution operators are following manufacturer best practices for parts, including the PermaLock mechanical tapping tee assembly. PHMSA will notify states of the updated questions when they are published. Furthermore, PHMSA will post the updated forms on our website. PHMSA's IA program is used by all federal-and some state-regulators, and it is therefore an efficient way to communicate pressing safety issues to pipeline regulators. To reach PHMSA's state partners, by August 31, 2019, PHMSA will update our Gas State Program Evaluation questionnaire to include an assessment of whether state inspectors have guidance on reviewing operators' use of manufacturer-recommended best practices in their operations and maintenance manuals and distribution integrity management programs. This guidance should include the use of specified tools and methods to correctly install PermaLock mechanical tapping tee assemblies. PHMSA is currently communicating with the National Association of Pipeline Safety Representatives (NAPSR) regarding these modifications. By January 31, 2019, PHMSA will also work with the American Public Gas Association (APGA) Security and Integrity Foundation (SIF) to include a set of questions regarding PermaLock mechanical tapping tee assemblies in the APGA SIF's Simple, Handy, Risk based Integrity Management Plan (SHRIMP) online tool for operators of natural gas distribution systems. Operators use SHRIMP to create a DIMP plan customized for the specific needs of their systems. PHMSA's work with APGA and APGA SIF has already begun. Actions to date include APGA forwarding the NTSB report and recommendations to its members, informing operators that risks identified with PermaLock mechanical tapping tee assemblies should be accounted for in an Operator's DIMP, and reminding operators that they should ensure that best practices recommended by the manufacturers are incorporated into applicable procedures in their required operations and maintenance manuals.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2019-06-14

Communication Type: Official Correspondence

Communication Contents: -From Howard R. Elliott, Administrator: PHMSA requests closure of this recommendation. PHMSA modified seven inspection questions in the Distribution Integrity Management Program Inspection Assistant (IA) involving Gas Distribution, Master Meter, and Small Liquefied Petroleum Integrity Management to address the issues associated with the installation of PermaLock mechanical tapping tee assemblies. PHMSA notified states of these changes by posting the revised IA question set on its website (https://www.phmsa.dot.gov/forms/pipeline-forms ). PHMSA also worked with the American Public Gas Association (APGA) Security and Integrity Foundation (SIF) to include a set of questions regarding PermaLock mechanical tapping tee assemblies in the APGA SIF's "Simple, Handy, Risk-Based Integrity Management Plan" (SHRIMP) online tool for operators. The updated SHRIMP tool was published on April 3, 2019 (http://apgasif.org/sif-tools/shrimpdimp/). APGA SIF additionally published PowerPoint slides and a webinar demo of the revised management plan that discuss issues associated with PermaLock installations (http://apgasif.org/shrimp-3-webinar-recordings/). PHMSA revised question C-1 7 in the Pipeline Safety Gas State Program Evaluation Evaluator Guidance to include a discussion on whether the state provided inspection guidance for inspectors to ensure that gas distribution pipeline operators are using best practices recommended by the manufacturers of PermaLock mechanical tapping tees in their operations and maintenance manuals and/or distribution integrity management programs. These best practices include using the specified tools and methods to correctly install PermaLock mechanical tapping tee assemblies. The revised guidance was made available to PHMSA's state evaluators on April 9, 2019. PHMSA takes its responsibility to address all NTSB recommendations seriously. PHMSA looks forward to working with your office as we continue to help ensure the safe, reliable, and environmentally sound operation of the Nation's pipeline transportation system. Thank you for your consideration regarding the closure of Recommendations P-15-16 and P-18-01.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2019-04-01

Communication Type: Official Correspondence

Communication Contents: -From Howard R. Elliott, Administrator: PHMSA received the NTSB's response to our proposed implementation plan on February 4, 2019, and appreciates that the NTSB has classified this recommendation as "Open-Acceptable Response." PHMSA is working to complete these actions and looks forward to the NTSB's future comments.