# NTSB Safety Recommendation P-21-015 - **operation:** document - **citation:** P-21-015 - **title:** NTSB Safety Recommendation P-21-015 - **source type:** guidance - **agency:** National Transportation Safety Board - **status:** guidance - **official:** true - **published on:** 2021-08-10 - **effective on:** 2021-08-10 - **summary:** TO THE SAN FRANCISCO POLICE DEPARTMENT, THE SAN FRANCISCO FIRE DEPARTMENT, AND THE SAN FRANCISCO DEPARTMENT OF EMERGENCY MANAGEMENT: Work with the Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. - **machine formats:** - **json:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-21-015.json - **markdown:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-21-015.md - **app url:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-21-015 - **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-21-015 **body:** NTSB safety recommendation P-21-015. TO THE SAN FRANCISCO POLICE DEPARTMENT, THE SAN FRANCISCO FIRE DEPARTMENT, AND THE SAN FRANCISCO DEPARTMENT OF EMERGENCY MANAGEMENT: Work with the Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. Priority: CLASS II Overall Status: Closed - Acceptable Action Issued Date: 2021-08-10 Adopted Date: 2021-07-26 Overall Date Closed: 2022-01-05 Synopsis: On February 6, 2019, at 1:07 p.m. local time, the excavator operator for a third-party contractor, Kilford Engineering Inc., impacted a Pacific Gas & Electric Company (PG&E) branch connection with a mini excavator trenching bucket attachment during mechanical excavation for fiberoptic conduit installation, which resulted in the release and ignition of natural gas. The accident occurred in the Richmond District of San Francisco, California. A nearby restaurant with a rental unit above caught fire. There were no injuries. Estimated damages to nearby buildings and the pipeline system exceeded $10 million. The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was the failure of the Kilford operator and spotter to follow safe excavation practices within the tolerance zone, which resulted in the mini excavator trenching bucket attachment impacting the pipeline’s branch connection. The investigators focused on the safety issues of third-party excavation damage to buried natural gas pipelines, enforcement challenges of California’s damage prevention law, PG&E’s data integration gaps during the development of the valve isolation plan, and insufficient joint emergency response planning between PG&E and San Francisco emergency response agencies. As a result of the investigation, the NTSB makes one recommendation each to the San Francisco Police Department, Fire Department, and Department of Emergency Management and two recommendations to PG&E. Probable Cause: The National Transportation Safety Board determines that the probable cause of the February 6, 2019, release of natural gas from the Pacific Gas & Electric Company distribution pipeline and the subsequent fire was the failure of the Kilford Engineering Inc. operator and spotter to follow safe excavation practices within the tolerance zone, which resulted in the mini excavator trenching bucket attachment impacting the pipeline’s branch connection. Ntsbnumber: PLD19MR001 Report Number: PAR-21-02 Addressee Name: State of California, City of San Francisco, Department of Emergency Management Addressee Status: Closed - Acceptable Action Addressee Date Closed: 2022-01-05 Addressee Acronym: SFDEM Addressee Organization Type: L-Local Government Communication Date: 2021-08-10 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 July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. 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-21-15). 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. 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 San Francisco Department of Emergency Management 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 July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendations can 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: • Third-party excavation damage to buried natural gas pipelines. • Enforcement challenges of California’s damage prevention law. • Pacific Gas & Electric Company’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between Pacific Gas & Electric Company and San Francisco, California, emergency response agencies. Accordingly, the NTSB makes the following safety recommendation to the San Francisco Department of Emergency Management. Additional information regarding this recommendation can be found in the noted sections of the report. • Work with Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. (P-21-15) (See section 2.5.) 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 P-21-15. 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: SFDEM Addressee Organization Type: L-Local Government Communication Date: 2021-11-08 Communication Type: Official Correspondence Communication Contents: -From Adrienne Bechelli, Deputy Director, Emergency Services: San Francisco is happy to respond to your letter referencing recommendation P-21-15 of the National Transportation Safety Board report citing the following: “Accordingly, the NTSB makes the following safety recommendation to the San Francisco Department of Emergency Management… Work with Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. (P-21-15)” Over the last three months, San Francisco emergency officials from the Department of Emergency Management, Police Department, Fire Department, and Pacific Gas & Electric Company have met to establish and accept a new protocol for a facilitated path of travel for utility crews arriving to an incident. The full protocol, effective immediately, is attached hereto. Please feel free to contact me if you have any questions. Addressee Acronym: SFDEM Addressee Organization Type: L-Local Government Communication Date: 2022-01-05 Communication Type: Official Correspondence Communication Contents: We note that officials from the SFDEM, the SFFD, and the SFPD met with PG&E representatives on October 13, 2021, and you collectively agreed to provide a coordinated response as needed to ensure the safe and timely arrival of utility personnel and equipment. We understand that the extent of the need will be determined jointly by fire personnel on scene and PG&E, coordinated by the SFDEM dispatch, and performed by SFPD personnel and PG&E. The SFDEM Watch Center will maintain overall situational awareness. We note that the agreement between the SFDEM, SFFD, SFPD, and PG&E clearly sets forth the roles and responsibilities for each party to the agreement and provides detailed response procedures for emergencies when PG&E is on scene and when PG&E is not on scene. Your agreement with PG&E satisfies Safety Recommendation P-21-15, which is classified CLOSED-- ACCEPTABLE ACTION. Addressee Name: State of California, City of San Francisco, Fire Department Addressee Status: Closed - Acceptable Action Addressee Date Closed: 2022-01-05 Addressee Acronym: SF Fire Addressee Organization Type: L-Local Government Communication Date: 2021-08-10 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 July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. 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-21-15). 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. 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 San Francisco Fire Department 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 July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendations can 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: • Third-party excavation damage to buried natural gas pipelines. • Enforcement challenges of California’s damage prevention law. • Pacific Gas & Electric Company’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between Pacific Gas & Electric Company and San Francisco, California, emergency response agencies. Accordingly, the NTSB makes the following safety recommendation to the San Francisco Fire Department. Additional information regarding this recommendation can be found in the noted section of the report. • Work with Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. (P-21-15) (See section 2.5.) 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, P-21-15. 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: SF Fire Addressee Organization Type: L-Local Government Communication Date: 2022-01-05 Communication Type: Official Correspondence Communication Contents: We note that officials from the SFDEM, the SFFD, and the SFPD met with PG&E representatives on October 13, 2021, and you collectively agreed to provide a coordinated response as needed to ensure the safe and timely arrival of utility personnel and equipment. We understand that the extent of the need will be determined jointly by fire personnel on scene and PG&E, coordinated by the SFDEM dispatch, and performed by SFPD personnel and PG&E. The SFDEM Watch Center will maintain overall situational awareness. We note that the agreement between the SFDEM, SFFD, SFPD, and PG&E clearly sets forth the roles and responsibilities for each party to the agreement and provides detailed response procedures for emergencies when PG&E is on scene and when PG&E is not on scene. Your agreement with PG&E satisfies Safety Recommendation P-21-15, which is classified CLOSED-- ACCEPTABLE ACTION. Addressee Name: State of California, City of San Francisco, Police Department Addressee Status: Closed - Acceptable Action Addressee Date Closed: 2022-01-05 Addressee Acronym: SFPD Addressee Organization Type: L-Local Government Communication Date: 2021-08-10 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 July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. 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-21-15). 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. 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 San Francisco Police Department 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 July 27, 2021, report, Pacific Gas & Electric Third-Party Line Strike and Fire, San Francisco, California, February 6, 2019. The details of this accident investigation and the resulting safety recommendations can 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: • Third-party excavation damage to buried natural gas pipelines. • Enforcement challenges of California’s damage prevention law. • Pacific Gas & Electric Company’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between Pacific Gas & Electric Company and San Francisco, California, emergency response agencies. Accordingly, the NTSB makes the following safety recommendation to the San Francisco Police Department. Additional information regarding this recommendation can be found in the noted section of the report. • Work with Pacific Gas & Electric Company to establish an agreement to provide a coordinated response and reduce response times for Pacific Gas & Electric Company’s crews to arrive at the scene of a pipeline accident. (P-21-15) (See section 2.5.) 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 its number, P-21-15. 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: SFPD Addressee Organization Type: L-Local Government Communication Date: 2022-01-05 Communication Type: Official Correspondence Communication Contents: We note that officials from the SFDEM, the SFFD, and the SFPD met with PG&E representatives on October 13, 2021. Collectively, you agreed to provide a coordinated response as needed to ensure a safe and timely arrival of utility personnel and equipment. We understand that the extent of the need will be determined jointly by fire personnel on-scene and PG&E, coordinated by the SFDEM dispatch, and performed by SFPD personnel and PG&E. The SFDEM Watch Center will maintain overall situational awareness. We note that the agreement between the SFDEM, SFFD, and SFPD and PG&E clearly sets forth the roles and responsibilities for each party to the agreement and provides detailed response procedures for emergencies when PG&E is on scene and when PG&E is not on scene. Your agreement with PG&E establishes a coordinated plan, that includes detailed procedures to reduce response times for PG&E crews to arrive at the scene of a pipeline accident. Accordingly, Safety Recommendation P-21-15 is classified CLOSED-- ACCEPTABLE ACTION. - **truncated:** false - **body characters:** 23397