NTSB Safety Recommendation P-19-017

NTSB safety recommendation P-19-017.

TO THE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY: Develop guidance that includes a component for effective communications when deploying mutual aid resources within the first hours of a multi-jurisdictional incident.

Priority: CLASS II

Overall Status: Closed - Exceeds Recommended Action

Issued Date: 2019-10-24

Adopted Date: 2019-09-24

Overall Date Closed: 2024-07-29

Synopsis: On September 13, 2018, about 4:00 p.m. local time, a series of structure fires and explosions occurred after high-pressure natural gas was released into a low-pressure natural gas distribution system in the northeast region of the Merrimack Valley in the Commonwealth of Massachusetts. The natural gas distribution system was owned and operated by Columbia Gas of Massachusetts, a subsidiary of NiSource, Inc. Columbia Gas of Massachusetts delivers natural gas to about 325,000 customers in Massachusetts. One person was killed and 22 individuals, including three firefighters, were transported to local hospitals due to injuries; seven other firefighters incurred minor injuries. The fires and explosions damaged 131 structures, including at least 5 homes that were destroyed in the city of Lawrence and the towns of Andover and North Andover. Most of the damage occurred from fires ignited by natural gas-fueled appliances; several of the homes were destroyed by natural gas-fueled explosions. Fire departments from the three municipalities were dispatched to the fires and explosions. First responders initiated the Massachusetts fire-mobilization plan and received mutual aid from neighboring districts in Massachusetts, New Hampshire, and Maine. Emergency management officials had the electric utility shut down electrical power in the area, the state police closed local roads, and freight and passenger railroad operations in the area were suspended. Columbia Gas of Massachusetts shut down the low-pressure natural gas distribution system, affecting 10,894 customers, including some outside the area who had their service shut off as a precaution. The National Transportation Safety Board made new recommendations to the Pipeline and Hazardous Materials Safety Administration; the 31 states with an industrial exemption for natural gas infrastructure projects; the Commonwealth of Massachusetts Executive Office of Public Safety and Security; and NiSource, Inc.

Probable Cause: The National Transportation Safety Board determines that the probable cause of the overpressurization of the natural gas distribution system and the resulting fires and explosions was Columbia Gas of Massachusetts’ weak engineering management that did not adequately plan, review, sequence, and oversee the construction project that led to the abandonment of a cast iron main without first relocating regulator sensing lines to the new polyethylene main. Contributing to the accident was a low-pressure natural gas distribution system designed and operated without adequate overpressure protection.

Keywords: Hazmat

Ntsbnumber: PLD18MR003

Report Number: PAR-19-02

Addressee Name: Commonwealth of Massachusetts

Addressee Status: Closed - Exceeds Recommended Action

Addressee Date Closed: 2024-07-29

Addressee Acronym: MA

Addressee Organization Type: S-State Government

Communication Date: 2019-10-24

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. The attached letter from the NTSB Chairman provides information about the NTSB’s September 24, 2019, report Overpressurization of Natural Gas Distribution System, Explosions, and Fires in Merrimack Valley, Massachusetts, September 13, 2018, NTSB/PAR-19/02. The details of this accident investigation and the resulting safety recommendation may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary. 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 of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendation by number (for example, P-19-16). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this recommendation. Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov or call (202) 314-6290 and ask to be directed to the Safety Recommendations Division. 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 assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the Commonwealth of Massachusetts Executive Office of Public Safety and Security to act on the safety recommendation in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary. This letter provides information about our September 24, 2019, report Overpressurization of Natural Gas Distribution System, Explosions, and Fires in Merrimack Valley, Massachusetts, September 13, 2018, NTSB/PAR-19/02. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of this investigation, we identified the following safety issues: • Adequacy of natural gas regulations • Project documentation • Constructability review • Project management • Risk assessment • Safety management systems ??Licensed professional engineer approval of natural gas projects • Emergency response Accordingly, the NTSB makes the following safety recommendation to the Commonwealth of Massachusetts Executive Office of Public Safety and Security. Additional information regarding this recommendation can be found in the noted section of the report. • Develop guidance that includes a component for effective communications when deploying mutual aid resources within the first hours of a multi-jurisdictional incident. (P-19-17) (See section 3.5.2.) The NTSB is vitally interested in this recommendation because it is designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement this recommendation. When replying, please refer to the safety recommendation by number (for example, P-19-17). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e-mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

Addressee Acronym: MA

Addressee Organization Type: S-State Government

Communication Date: 2024-06-21

Communication Type: Official Correspondence

Communication Contents: -From Richard H. Fiske, Statewide Interoperability Coordinator (SWIC), Massachusetts Executive Office of Public Safety and Security: The Massachusetts Executive Office of Public Safety and Security (EOPSS) is pleased to submit the following information in response to Public Safety Recommendation P-19-17 included in your September 13, 2019, report, “Over Pressurization of Natural Gas Distribution System. Explosions and Fires in Merrimack Valley, Massachusetts”. P-19-17 recommends that Massachusetts “Develop guidance that includes a component for effective communications when deploying mutual aid resources within the first hours of a multi-jurisdictional incident”. Since the September 14, 2018, Merrimack Valley pipeline accident, the Commonwealth has made investments and dedicated resources to furthering its interoperability capabilities. The Statewide Office of Public Safety Interoperability within EOPSS engaged with stakeholders through publications and established equipment, training and exercise requirements. Examples of initiatives that address the recommendation are as follows: Massachusetts Fire Mobilization Plan o The Fire Mobilization Plan, first published in early 2020, is a statewide plan developed with cooperation and participation from local fire departments, the Massachusetts’s Departments of Fire Services and Public Health, the Office of Emergency Medical Services, the Emergency Management Agency (MEMA), the State Emergency Operations Center, Fire District Control Points and the Statewide Interoperability Coordinator (SWIC). The plan provides guidance and direction during multi-jurisdictional Task Force and Strike Team activations, including directly addressing the use of interoperable communications resources and guidance. To support more effective communications between responders the committee recommended updating the “run card” to include communications assets, teams, or personnel upon initial deployments. Public Safety Communications Best Practice Guidance o In early 2022, the Statewide Interoperability Coordinator’s Office published the “Massachusetts Interoperable Emergency Communications Best Practices.” This document provides guidance to agencies as they develop policies and procedures for communications and interoperable resource utilization and planning. Massachusetts Tactical Channel Plan Updates • The updated Tactical Channel Plan includes all multi-disciplinary interoperability channel resources in Massachusetts and the National Non-Federal Channels. In addition, the updated plan includes guidance on programming and use of these resources. Commonwealth Interoperable Radio System (CoMIRS) Statewide upgrade o In 2020, the Executive Office of Technology Services and Security, EOPSS, the State Police Communications Section, the State 911 Department and the SWIC began working on a $125 million upgrade and expansion of the Commonwealth’s only statewide interoperable radio system. Scheduled to be completed in 2026, this statewide system facilitates interoperability between any agency or discipline, anywhere in the state, to any area within its coverage footprint. Public Safety Equipment Statewide Contract (PSE-01) – Interoperability Requirements o This updated statewide contract, developed with input from the SWIC, includes requirements that regardless of funding source, any agency leveraging the statewide contract for public safety radio equipment must procure Public Safety Analog or “P25” digital equipment, which is universally interoperable regardless of the equipment manufacturer. EOPSS and Homeland Security Grant Program (HSGP) Grant Guidance o The Office of Grants and Research (OGR), as the State Administrating Agency (SAA), worked with the SWIC to update HSGP guidance for agencies seeking funding for full scale or functional training and exercises. The new guidance requires agencies to include a Communications and Interoperability Component. In drills and exercises participating agencies need to demonstrate the ability to execute the necessary communications and interoperability tasks during large multi-jurisdictional events. After Action Reports from the drills and exercises are reviewed by the SWIC to identify needs, gaps, or successes. In practice this new requirement has served as an opportunity to confirm that agencies and municipalities have updated and programed their equipment in compliance with the MTCP. o In coordination with the ongoing effort to expand agency equipment capabilities, any equipment funded under HSGP or using state funds must follow the published Interoperable Communications Investment Proposal (ICIP). o All communications equipment purchase proposals using any grant funding through OGR, the Massachusetts Gaming Commission, MEMA, or the State 911 Department are now reviewed by the SWIC ensuring that equipment purchased satisfy the interoperable standards outlined in the ICIP. Stakeholder Outreach, Training and Education o Working in collaboration with other stakeholder agencies the SWIC has increased the amount of stakeholder outreach with presentations to recruit training groups, in service training, and promotion level training courses in all disciplines. This outreach addresses the importance of communications and interoperability when planning for multi-jurisdictional events and the need to conduct specific training for street level responders so they can effectively leverage the resources available during emergencies. o EOPSS has funded a full-time Assistant SWIC position. o The SWIC and Assistant SWIC, when needed, respond within the first hours of an incident to provide guidance and assistance. While the efforts outlined above demonstrate the Commonwealth’s continued commitment to expanding interoperability and communications capabilities statewide, these are just some examples of the work we are doing in this space. Interoperability is not just a technology issue; it is a people and relationships issue. Fostering the relationships between agencies and disciplines on blue sky days, making investments in technology, training, and personnel, and adopting recommended best practices from this office, SAFECOM, the National Council of Statewide Interoperability Coordinators (NCSWIC), the Association of Public Safety Communications Officers (APCO), and other recognized standards setting bodies will only further the efforts, and we continuously encourage all public safety agencies in Massachusetts to do so. Please feel free to contact me if you would like more information in this regard.

Addressee Acronym: MA

Addressee Organization Type: S-State Government

Communication Date: 2022-05-16

Communication Type: Official Correspondence

Communication Contents: In the 2 years since we issued this recommendation, we have not received any information from you regarding your actions to implement it. When we issued this recommendation, we asked that you advise us within 90 days detailing any actions you had taken or intended to take in response. We would appreciate receiving a response from you within 90 days regarding actions that you have completed or planned to address this recommendation. Safety Recommendation P-19-7 is currently classified OPEN-- AWAIT RESPONSE.

Addressee Acronym: MA

Addressee Organization Type: S-State Government

Communication Date: 2024-07-29

Communication Type: Official Correspondence

Communication Contents: We note that, since the Merrimack Valley pipeline accident, Massachusetts has invested in and dedicated resources to furthering the state’s emergency response communications capabilities. Your state took the following initiatives to address this recommendation: • Published a Fire Mobilization Plan in early 2020. This plan provides guidance and direction during multijurisdictional Task Force and Strike Team activations, including directly addressing the use of interoperable communications resources. • Published “Massachusetts Interoperable Emergency Communications Best Practices” in 2022 for agencies developing procedures for communication and interoperable resource planning. • Updated your Tactical Channel Plan to include all multidisciplinary interoperability channel resources in Massachusetts and national nonfederal channels. • Began upgrading the Commonwealth Interoperable Radio System, which facilitates interoperability between any agency or discipline anywhere in the state to any area within its coverage footprint. • Updated your Public Safety Equipment Statewide Contract (PSE-01) – Interoperability Requirements to include a requirement that, regardless of funding source, any agency leveraging the statewide contract for public safety radio equipment must procure public safety analog or “P25” digital equipment, which is universally interoperable regardless of the equipment manufacturer. • Updated Homeland Security Grant Program (HSGP) grant guidance for agencies seeking funding for full-scale or functional training and exercises. The new guidance requires agencies to include a communications and interoperability component. In drills and exercises, participating agencies need to demonstrate the ability to execute the necessary communications and interoperability tasks during large, multijurisdictional events. After action reports from the drills and exercises are reviewed by the SWIC to identify needs, gaps, or successes. Any equipment funded under the HSGP or using state funds must follow the published Interoperable Communications Investment Proposal (ICIP), and all communications equipment purchase proposals using any grant funding through the Office of Grants and Research, the Massachusetts Gaming Commission, the Massachusetts Emergency Management Agency, or the State 911 Department are now reviewed by the SWIC, who ensures that equipment purchased satisfies the interoperable standards outlined in the ICIP. • Increased stakeholder outreach with presentations to recruit training groups, in-service training, and promotion-level training courses in all disciplines. This outreach addresses the importance of communications and interoperability when planning for multijurisdictional events and the need to conduct specific training for street-level responders so they can effectively leverage available resources during emergencies. • Funded an assistant SWIC position. We commend you for taking significant actions beyond what we recommended to address this safety issue. Accordingly, Safety Recommendation P-19-17 is classified CLOSED-- EXCEEDS RECOMMENDED ACTION. Thank you for your taking these actions to improve communications interoperability across your state.