NTSB Safety Recommendation P-18-003

NTSB safety recommendation P-18-003.

TO HONEYWELL: Update your PermaLock mechanical tapping tee assembly installation instructions to specify the exact tools that should be used during installation and explain what an installer should sense while using those tools throughout the installation process.

Priority: CLASS II

Overall Status: Closed - Acceptable Alternate Action

Issued Date: 2018-06-25

Adopted Date: 2018-06-15

Overall Date Closed: 2019-03-12

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: Honeywell International, Inc.

Addressee Status: Closed - Acceptable Alternate Action

Addressee Date Closed: 2019-03-12

Addressee Organization Type: P-Private Industry

Communication Date: 2018-06-25

Communication Type: Transmittal Letter

Communication Contents: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. On June 18, 2018, the 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 Honeywell, 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 Organization Type: P-Private Industry

Communication Date: 2018-08-22

Communication Type: Official Correspondence

Communication Contents: -From Edward Myszka, Vice President and General Manager: Honeywell1 acknowledges and appreciates the substantial efforts of the National Transportation Safety Board's (the "Board") staff in connection with its response to Incident #DCA 17FP006, its investigation of the causes thereof, and its efforts to address and enhance industry safety. Honeywell's Perfection business has supported and cooperated fully with the Board and its staff throughout this process and commits to continue to do so in the future. In particular, Perfection commits to work collaboratively with the Board and its staff in regards to Recommendations P-18-3 and P-18-4. Our commitment to health, safety and the environment is an integral aspect of our design of products, processes and services. Honeywell's Health, Safety, Environmental, Product Stewardship and Sustainability (HSEPS) Management practices are managed by a global team of trained professionals with extensive knowledge and hundreds of years of collective experience. We support the spirit behind the recommendations (i.e ., improving safety) and include herewith revised installation instructions for Perfection Permalock® tapping tees - we've made enhancements in the interest of continuous improvement and refinement; however, we maintain that our instructions were not and have never been inadequate in any way. Further, we believe it beneficial to offer clarification concerning some of the Board's findings and suggestions. This letter addresses: 1) Federal Regulations and corresponding installer qualification requirements that have come into existence since the installation of the tees in question 2) The fact that the installer appears to have disregarded the written instructions provided with the tees 3) Specific concerns with respect to Recommendations P-18-3 and P-18-4 Updates to Federal Regulations As acknowledged by the Board, since the 1998 installation of the tee at issue, new federal regulations concerning operator qualification and training were adopted. The Operator Qualification (OQ) rule was adopted into the Code of Federal Regulations under Subpart Nin 49 CFR Part 192 and Subpart Gin 49 CFR Part 195. Under the rule, each pipeline operator is responsible for developing an OQ program, following their written OQ plan, establishing a covered task list applicable to their system, and defining the training and qualification requirements for personnel performing covered tasks on their pipeline facility. It is the operator's responsibility to ensure their contractors and vendors comply with their program requirements. 49 CFR Part 192 was passed in 1999 and amended in 2005. The stated objective of this rule was to reduce the risk of accidents on pipeline facilities attributable to human error. It is intended to provide an additional level of safety by requiring operators of pipelines and natural gas distribution systems to develop qualification programs to evaluate an individual's ability to perform covered tasks. The qualification programs should also ensure that personnel can recognize and react to abnormal operating conditions that may occur while performing covered tasks. As noted in the report, " ... when the tee assembly involved in the accident was installed in 1998, federal regulations concerning operator qualification training standards for installation of tee assemblies did not exist, and UGI did not have a training program for installing them ... " The Operator Qualification rule, designed to reduce casualty incidents, was not in effect when the Permalock® tee was installed. Disregard of Written Instructions In 1998, UGI was relying solely on each of its individual installers to follow the written installation instructions shipped with the tee assembly2• The report states: "NTSB examination of the Permalock® tee assembly involved in the accident has revealed that the tee assembly was incorrectly installed. Although the cutter tool pierced a hole in the main, the locking sleeve did not progress down far enough into the tower to form threads in that hole. As a result, the locking sleeve was not attached to the main." In other words, the installer of the tee in question did not follow the written installation instructions, at a minimum Step 6 of the instructions (set forth below) was omitted. The depth tube was not used, and as a result, the steel locking sleeve never engaged the main. This was evidenced by the lack of formed threads through the entire crosssection of the pipe wall. The punched bore through the exhumed pipe was smooth. During a proper installation, the sleeve always produces a double-lead thread form in the pipe wall. The steel locking sleeve is designed to serve as the primary anchor to the main; preventing radial, lateral and rotational movement. If the instructions were followed, and the depth tube utilized, this incident would not have occurred. Written instructions, no matter how detailed or clearly presented, are only useful if the installer follows them. Specific Concerns with Respect to Recommendations The recommendations made by the Board were: 1. Update your Permalock® mechanical tapping tee assembly installation instructions to specify the exact tools that should be used during installation and explain what an installer should sense while using those tools throughout the installation process. (P-18-3) 2. Specify in your Permalock® mechanical tapping tee assembly installation instructions a not-to exceed torque limit for Nylon bolts and have that value checked and adjusted with a torque wrench immediately after installation. (P-18-4) Prescribing Exact Tool Size A general description of tool length may provide some benefit. However, using a shorter wrench is subjective rather than objective and does not guarantee or increase the likelihood of a proper installation. Therefore, while we don't think it's necessary, we have added guidance in the updated instructions submitted with this letter. Installers Should Follow Written Directions and Not Rely on Sense The use of a depth tube to verify the proper installation of the cutter sleeve is included in both the previous and current installation instructions. This removes the need for subjective sensory input, such as the torque changes between the punching of the main line, and the installation of the cutter sleeve. As mentioned above, the failure of the installer to follow instructions and use the depth tube was the cause of the incorrect installation. The installation instructions which were reviewed during this investigation were p/n 37575 revision level F, which was the active revision level at the time of installation. These instructions are currently at revision level R. The modifications that have been made to the installation instructions were either made to offer increased clarity to the end user, or to due to design changes to the Permalock® tapping tee which required clarification of the instructions. The installation instructions (both current and previous revisions) explicitly and objectively state the following: • Revision F , Step 6: Place DEPTH TUBE on top of the CUTTER ASSEMBLY. Thread CUTTER ASSEMBLY downward using a 5/16" hex wrench. Continue threading the CUTTER ASSEMBLY downward until it becomes snug. The DEPTH TUBE will be flush to 1/8" above the top of the TEE TOWER. • Revision R4 , Step 1: ... NOTE: A blue colored depth tube is required for 1 1/4 IPS main installation, and a white colored depth tube is required for 2-4 IPS main installation. If you do not have the proper color depth tube, DO NOT install the fitting. • Revision R, Step 6: Place DEPTH TUBE on top of the CUTTER ASSEMBLY. Thread CUTTER ASSEMBLY downward using a 5/16" hex wrench. Continue threading the CUTTER ASSEMBLY downward until it bottoms in the tower. The DEPTH TUBE is a visual guide and will be approximately flush with the top of the Tee Tower when the cutter is engaged. As dem

Addressee Organization Type: P-Private Industry

Communication Date: 2019-03-12

Communication Type: Official Correspondence

Communication Contents: We issued this recommendation after concluding that the PMTT installation instructions did not provide enough information. We determined that the instructions should specify the exact tools that are most effective for attaching a locking sleeve to a main and should emphasize that a depth tube should be used to verify that attachment. Our reference to an “exact tool” came from our review of a video that discussed the “feel” on the installation wrench as a guide for proper installation, and how this was masked when using a 19-inch wrench. We note that you do not believe the video should be used to provide installation instructions, and you do not endorse using the feel on the installation wrench as a guide. However, to satisfy this recommendation, you modified your installation instructions to specify that the wrench handle used should be no longer than 12 inches, and you emphasized how to properly use the supplied depth tube during installation. Revision F of your installation instructions, Step 6, stated “Continue threading the CUTTER ASSEMBLY downward until it becomes snug. The DEPTH TUBE will be flush to 1/8” above the top of the TEE TOWER.” In a later revision (Revision R), that phrase was replaced with “Continue threading the CUTTER ASSEMBLY downward until it bottoms in the tower. The DEPTH tube is a visual guide and will be approximately flush with the top of the tee tower when the cutter is engaged.” We believe this new language more precisely describes the actions that are necessary for installing the locking sleeve, and it will eliminate the need for a technician to measure the height of the depth tube relative to the surface of the pipe. We believe that the “feel” process provides the technician with an additional layer of confidence that the installation is progressing as intended. At present, the problem of improper locking sleeve installation appears to be isolated to one gas utility operator, as we are not aware of difficulty reports from other gas operators regarding locking sleeve installation. The revised instructions, which direct technicians to use the depth tube and specify the maximum wrench length for installation, are alternatives that satisfy this recommendation. Accordingly, Safety Recommendation P-18-3 is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.