{"operation":"document","citation":"P-21-003","title":"NTSB Safety Recommendation P-21-003","source_type":"guidance","agency":"National Transportation Safety Board","status":"guidance","official":true,"published_on":"2021-02-08","effective_on":"2021-02-08","summary":"TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Assist the Railroad Commission of Texas in conducting the audit recommended in Safety Recommendation P-21-4.","machine_formats":{"json":"https://regulus.evalyn.ai/document/ntsb-recommendation-p-21-003.json","markdown":"https://regulus.evalyn.ai/document/ntsb-recommendation-p-21-003.md"},"app_url":"https://regulus.evalyn.ai/document/ntsb-recommendation-p-21-003","source_url":"https://data.ntsb.gov/carol-main-public/sr-details/P-21-003","body":"NTSB safety recommendation P-21-003.\n\nTO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Assist the Railroad Commission of Texas in conducting the audit recommended in Safety Recommendation P-21-4.\n\nPriority: CLASS II\n\nOverall Status: Closed - Acceptable Action\n\nIssued Date: 2021-02-08\n\nAdopted Date: 2021-01-12\n\nOverall Date Closed: 2024-10-09\n\nSynopsis: On February 23, 2018, at 6:38 a.m. local time, a natural gas–fueled explosion occurred at 3534 Espanola Drive, Dallas, Texas. The residence sustained major structural damage, but when first responders arrived on scene at 6:44 a.m., they observed no smoke or fire. Four family members were injured, and one was killed in the explosion. Following the explosion, National Transportation Safety Board (NTSB) investigators located a through-wall crack in the 71 year old natural gas main that served the residence. In the 2 days before this explosion, two gas-related incidents occurred on the same block at houses that were served by the same natural gas main, each resulting in significant structural damage and burn injuries to one occupant. The first occurred on February 21, 2018, at 5:49 a.m., and resulted in one injury involving second-degree burns and significant structural damage to 3527 Durango Drive. The second incident occurred on February 22, 2018, at 10:21 a.m., and resulted in one injury involving second-degree burns and significant structural damage to 3515 Durango Drive. As a result of this investigation, the NTSB issued new safety recommendations to the Pipeline and Hazardous Materials Safety Administration, the Railroad Commission of Texas, the Dallas Fire-Rescue Department, Atmos Energy Corporation, and the Gas Piping Technology Committee. The NTSB is also reiterating safety recommendations to the International Code Council, the National Fire Protection Association, and the Gas Technology Institute\n\nProbable Cause: The National Transportation Safety Board determines that the probable cause of the explosion at 3534 Espanola Drive was the ignition of an accumulation of natural gas that leaked from the gas main that was damaged during a sewer replacement project 23 years earlier and was undetected by Atmos Energy Corporation’s investigation of two related natural gas incidents on the 2 days prior to the explosion. Contributing to the explosion was Atmos Energy Corporation’s insufficient wet weather leak investigation procedures. Contributing to the severity of the explosion was Atmos Energy Corporation’s inaction to isolate the affected main and evacuate the houses. Contributing to the degradation of the pipeline system was Atmos Energy Corporation’s inadequate integrity management program.\n\nNtsbnumber: PLD18FR002\n\nReport Number: PAR-21-01\n\nAddressee Name: PHMSA\n\nAddressee Status: Closed - Acceptable Action\n\nAddressee Date Closed: 2024-10-09\n\nAddressee Acronym: PHMSA\n\nAddressee Organization Type: G-Federal Government\n\nCommunication Date: 2021-02-08\n\nCommunication Type: Transmittal Letter\n\nCommunication Contents: The attached letter from the NTSB Chairman provides information about the NTSB’s January 12, 2021, report Atmos Energy Corporation Natural Gas-Fueled Explosion, Dallas, Texas, February 23, 2018, PAR-21/01. 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. 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 recommendations by number (for example, P 21-1 through -3). 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. This letter provides information about the National Transportation Safety Board’s (NTSB) January 12, 2021, report Atmos Energy Corporation Natural Gas-Fueled Explosion, Dallas, Texas, February 23, 2018, PAR-21/01. 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: • Incident investigation. Neither Dallas Fire-Rescue Department (DFR) nor Atmos Energy Corporation (Atmos) identified the causes of the two incidents that occurred in the days immediately preceding the explosion. DFR arson investigators and Atmos technicians did not effectively investigate, communicate, or collaborate to determine the cause of either incident. Further, Atmos did not gather enough evidence to determine if gas migrated from their piping and fueled the first two incidents. • Leak investigations and repairs. Atmos dedicated significant resources to its response following the second incident, finding 13 leaks determined to present an existing or probable future hazard. However, none of its employees questioned the integrity of the system. As a result, Atmos did not take appropriate action to secure the safety of the area and its residents. This was attributed, in part, to inadequate procedures for performing leak investigations in wet weather conditions. • Methane detection. Although Atmos added odorant to its gas distribution system in a manner consistent with Pipeline and Hazardous Materials Safety Administration (PHMSA) regulations, none of the residents at any of the affected homes smelled gas. Although odorant can act as an early warning of a gas release to prevent an explosion and fire, it is known to become depleted if it travels through soil. • Incident reporting. Incident reporting requirements mandated by the PHMSA rely on the judgement of the operator to determine whether an incident resulted from a leak in their system and do not specify the level of investigation necessary to make the determination. While operators have an option to report events that may have been caused by their system, Atmos relied on an incomplete investigation to support its position not to report the first two incidents. Accordingly, the NTSB makes the following safety recommendations to PHMSA. Additional information regarding these recommendations can be found in the noted sections of the report. • Expand incident reporting requirements in Title 49 Code of Federal Regulations Part 191 so that events that may meet the definition of “incident” are immediately reported to the National Response Center even when the source of the natural gas has not been determined. (P 21-1) (See section 2.6.1.) • Evaluate industry’s implementation of the gas distribution pipeline integrity management requirements and develop updated guidance for improving their effectiveness. The evaluation should specifically consider factors that may increase the likelihood of failure such as age, increase the overall risk (including factors that simultaneously increase the likelihood and consequence of failure), and limit the effectiveness of leak management programs. (P 21-2) (See section 2.7.) • Assist the Railroad Commission of Texas in conducting the audit recommended in Safety Recommendation P-21-4. (P-21-3) (See section 2.7.) 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 recommendations by number (Safety Recommendation(s) P-21-1 through -3). 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. Please do not submit both an electronic copy and a hard copy of the same response.\n\nAddressee Acronym: PHMSA\n\nAddressee Organization Type: G-Federal Government\n\nCommunication Date: 2021-07-16\n\nCommunication Type: Official Correspondence\n\nCommunication Contents: We note that you will work with the RRC to conduct a comprehensive audit of Atmos’s incident reporting practices; its policies and procedures for responding to leaks, fires, explosions, and emergency calls; and its DIMP. Pending the completion of this audit, Safety Recommendation P-21-3 is classified OPEN-- ACCEPTABLE RESPONSE.\n\nAddressee Acronym: PHMSA\n\nAddressee Organization Type: G-Federal Government\n\nCommunication Date: 2024-10-09\n\nCommunication Type: Official Correspondence\n\nCommunication Contents: We note that you assisted the Railroad Commission of Texas with a comprehensive audit of Atmos Energy Corporation’s incident reporting practices; policies and procedures for responding to leaks, fires, explosions, and emergency calls; and integrity management programs. You expressed no concerns with the audit and have requested that we close this safety recommendation. Because you have completed our recommended action, Safety Recommendation P-21-3 is classified CLOSED-- ACCEPTABLE ACTION.\n\nAddressee Acronym: PHMSA\n\nAddressee Organization Type: G-Federal Government\n\nCommunication Date: 2022-05-02\n\nCommunication Type: Official Correspondence\n\nCommunication Contents: In our July 16, 2021, response to your May 3, 2021, letter about these recommendations, we classified Safety Recommendation P-21-1 “Open—Acceptable Alternate Response” and Safety Recommendations P-21-2 and -3 OPEN-- ACCEPTABLE RESPONSE.\n\nAddressee Acronym: PHMSA\n\nAddressee Organization Type: G-Federal Government\n\nCommunication Date: 2022-01-14\n\nCommunication Type: Official Correspondence\n\nCommunication Contents: -From Tristan H. Brown, Deputy Administrator: PHMSA provided NTSB with an alternate response for this recommendation on May 3, 2021, and looks forward to NTSB accepting our response.\n\nAddressee Acronym: PHMSA\n\nAddressee Organization Type: G-Federal Government\n\nCommunication Date: 2021-05-03\n\nCommunication Type: Official Correspondence\n\nCommunication Contents: -From Tristan Brown, Acting Administrator: We concur. In conjunction with the Railroad Commission of Texas (RRC), PHMSA will monitor Atmos’ completion of NTSB Safety Recommendations P-21-11 and P-21-12. Once completed, PHMSA will coordinate with and assist the RRC in conducting a comprehensive audit of Atmos’ incident reporting practices, its policies and procedures for responding to leaks, fires, explosions, and emergency calls, and the company’s DIMP.\n\nAddressee Acronym: PHMSA\n\nAddressee Organization Type: G-Federal Government\n\nCommunication Date: 2024-08-09\n\nCommunication Type: Official Correspondence\n\nCommunication Contents: -From Tristan H. Brown, Deputy Administrator: I am writing to request closure of the National Transportation Safety Board (NTSB) Safety Recommendation P-21-003 to the Pipeline Hazardous Materials Safety Administration (PHMSA), which was made as part of the NTSB’s January 12, 2021, Pipeline Accident Report 21/01 (PAR 21/01) regarding the natural gas explosion that occurred on February 23, 2018, in Dallas, Texas. Specifically, the NTSB recommended that PHMSA: • Assist the Railroad Commission of Texas in conducting the audit recommended in Safety Recommendation P-21-4. (P-21-003) The NTSB recommended to the Railroad Commission of Texas (TxRRC): • With assistance from the Pipeline and Hazardous Materials Safety Administration, conduct a comprehensive audit of Atmos Energy Corporation’s incident reporting practices; policies and procedures for responding to leaks, fires, explosions, and emergency calls; and integrity management programs. (P-21-004) PHMSA’s mission is to protect people and the environment by advancing the safe transportation of energy and other hazardous materials that are essential to our daily lives. PHMSA shares the NTSB's commitment to preventing pipeline accidents and has a long history of cooperating and collaborating with the NTSB. In response to the NTSB’s Safety Recommendation P-21-004, TxRRC conducted1 a comprehensive audit of Atmos Energy Corporation’s (Atmos) incident reporting practices, policies, and procedures for responding to leaks, fires, explosions, and emergency calls, and integrity management programs. This audit by TxRRC spanned a two-month period from February through April 2022, with in-person reviews held February 28 to March 3, 2022; March 28 to April 1, 2022; and April 25 to April 29, 2022. In accordance with NTSB Safety Recommendation P-21-003, PHMSA assisted TxRRC in conducting its comprehensive audit of Atmos. PHMSA notes that in NTSB’s August 23, 2022, response to TxRRC, the NTSB stated that “[t]hese actions [Atmos’ audit in response to NTSB Recommendation P-21-004] satisfy the intent of Safety Recommendation P-21-004, which is classified Closed-Acceptable Action.” PHMSA provided the necessary assistance to TxRRC to conduct the audit required by Safety Recommendation P-21-004; therefore, I am requesting that Safety Recommendation P-21-003 be classified “Closed-Acceptable Action.” PHMSA takes our responsibility to fully address all NTSB recommendations seriously and works hard to continuously improve its pipeline safety program. PHMSA looks forward to working with your office as it continues to strive to ensure the safe, reliable, and environmentally sound operation of the nation’s pipeline transportation system. If you have any questions or require additional information, please do not hesitate to contact me, or have your staff contact Damon Hill, Deputy Director of Governmental, International, and Public Affairs.","truncated":false,"body_characters":13865}