# NTSB Safety Recommendation P-21-016

- **operation:** document
- **citation:** P-21-016
- **title:** NTSB Safety Recommendation P-21-016
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 2021-08-10
- **effective on:** 2021-08-10
- **summary:** TO PACIFIC GAS & ELECTRIC COMPANY: In collaboration with the San Francisco Police Department, San Francisco Fire Department, and the San Francisco Department of Emergency Management establish an agreement to provide a coordinated response and reduce response times for your crews to arrive at the scene of a pipeline accident.
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- **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-21-016
**body:**

NTSB safety recommendation P-21-016.

TO PACIFIC GAS & ELECTRIC COMPANY: In collaboration with the San Francisco Police Department, San Francisco Fire Department, and the San Francisco Department of Emergency Management establish an agreement to provide a coordinated response and reduce response times for your 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: Pacific Gas and Electric Company

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2022-01-05

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

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-21-16 and P-21-17). 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 Pacific Gas & Electric Company (PG&E) to act on the safety recommendations 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. • PG&E’s data integration gaps during the development of the valve isolation plan. • Insufficient joint emergency response planning between PG&E and San Francisco, California, emergency response agencies. Accordingly, the NTSB makes the following safety recommendations to PG&E. Additional information regarding these recommendations can be found in the noted sections of the report. • In collaboration with the San Francisco Police Department, San Francisco Fire Department, and the San Francisco Department of Emergency Management, establish an agreement to provide a coordinated response and reduce response times for your crews to arrive at the scene of a pipeline accident. (P-21-16) (See section 2.5.) • Complete the integration of detailed location data into your hydraulic modeling software so that this information is readily available for all system assets when developing a valve isolation plan. (P-21-17) (See section 2.4) 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 R-21-16 or R-21-17. 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: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2022-01-05

Communication Type: Official Correspondence

Communication Contents: We note that you met with representatives from the SFPD, SFFD, and SFDEM on October 13, 2021, and that, collectively, you agreed that PG&E’s response to an event would be facilitated 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 coordinated agreement between PG&E, the SFDEM, the SFFD, and the SFPD 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. We further note that you have designated a public safety specialist who is available to San Francisco public safety entities and regularly coordinates with PG&E field personnel. Since 2019, you have provided approximately 72 gas and electric safety training sessions (First Responder Workshops) to members of the SFPD and SFFD. This training includes on-scene safety and response considerations to optimize the resources of both PG&E and the associated public safety partners. Your agreement with the SFDEM, SFFD, and SFPD satisfies Safety Recommendation P-21-16, which is classified CLOSED-- ACCETPABLE ACTION.

Addressee Acronym: PG&E

Addressee Organization Type: P-Private Industry

Communication Date: 2021-11-04

Communication Type: Official Correspondence

Communication Contents: -From Adam Wright, Executive Vice President, Operations and Chief Operating Officer, Pacific Gas and Electronic Company: Thank you for the opportunity to respond to the National Transportation Safety Board’s (NTSB) safety recommendations of August 10, 2021 resulting from its investigation of the February 6, 2019 gas dig-in incident at Parker and Geary Streets in San Francisco, California, and for providing the NTSB’s July 27, 2021 report. 1 There is nothing more important at Pacific Gas and Electric Company (PG&E) than the safety of the public and our employees, and these safety recommendations will help us continue to make improvements in these vital areas. As a result of the After-Action Review PG&E performed following the event, we have made improvements to our Damage Prevention program within San Francisco and across the State of California to reduce the risk of future accidents. One of these efforts was to reach out to the primary contractors from that event, Verizon and Mastec, as well as their sub-contractors, to hold safe digging awareness and 811 workshops. PG&E’s Damage Prevention team held meetings with Verizon, Mastec, and their sub-contractors on 8 occasions between 10/04/2019 and 06/25/2020 for 811 dig safe training. In addition, we have also conducted 811 training with Mastec an additional 5 times in 2021 emphasizing the 811 process, California excavation laws, high priority facilities, and safe excavation best practices. The following responses provide a detailed summary of the progress PG&E has made towards implementing the NTSB’s two safety recommendations (P-21-016 and P-21-017). PG&E’s Response to NTSB Recommendation P-21-16, dated August 10, 2021 Since 2019, the PG&E Public Safety Specialist group has provided approximately 72 gas and electric safety training sessions (First Responder Workshops) to members of the San Francisco Police and Fire Departments. This training included on-scene safety and response considerations, which serve to optimize the resources of both PG&E and the associated public safety partners. As part of this engagement, there is an assigned PG&E Public Safety Specialist who is available to the San Francisco public safety entities and regularly coordinates with PG&E field personnel. Specific to the NTSB recommendation, PG&E met with representatives from the San Francisco Fire Department (SFFD), Police Department (SFPD), and the Department of Emergency Management (SFDEM) on October 13, 2021. The referenced stakeholders agreed, based upon the extent of the emergency, that PG&E’s response to an event would be facilitated and/or assisted as needed to ensure a safe and timely arrival of utility personnel and equipment. The extent of the need will be determined jointly by fire personnel on-scene and PG&E, coordinated/facilitated by the SFDEM dispatch, and performed by SFPD personnel and PG&E. The SFDEM Watch Center will maintain overall situational awareness. In the event of an identified response support need, the following process will be initiated: PG&E Is On Scene of the Pipeline Emergency • SFFD and PG&E will coordinate to identify the estimated time of arrival (ETA) of additional needed PG&E resources and jointly determine whether a facilitated path of travel is necessary. If so, the following steps will be taken: • SFFD will notify SFDEM dispatch that a facilitated path of travel is required. • SFDEM will coordinate with SFPD and PG&E to identify a meeting location and path of travel. • SFPD and PG&E will meet at the designated location and proceed to the scene. • SFPD will notify SFDEM dispatch of their ETA to the scene. • SFDEM dispatch will relay the ETA to SFFD on scene. • SFFD will notify SFDEM dispatch once PG&E resources have arrived on scene. • PG&E will determine if gas shutoff can occur on scene or at a different location. • PG&E will coordinate with SFPD for a facilitated path of travel and communicate with SFFD should the gas shutoff need to occur at a different location. • SFPD will notify SFDEM dispatch of their ETA to the location. • PG&E and SFFD will confirm all resources no longer require a facilitated path of travel and notify SFDEM dispatch. • SFPD will notify SFDEM dispatch and will be released from the incident. PG&E Is Not On Scene of the Pipeline Emergency • SFFD will notify SFDEM dispatch that a pipeline emergency exists and request PG&E resources respond to the scene. • SFDEM dispatch will contact PG&E to provide situation information, request resources, and obtain an ETA. • SFDEM dispatch will provide SFFD on scene with the ETA for PG&E resources. • SFFD and PG&E will jointly determine whether a facilitated path of travel is required. • SFFD will notify SFDEM dispatch that a facilitated path of travel is required. • SFDEM will coordinate with SFPD and PG&E to identify a meeting location and path of travel. • SFPD and PG&E will meet at the designated location and proceed to the scene. • SFPD will notify SFDEM dispatch of their ETA to the scene • SFDEM dispatch will relay the ETA to SFFD on scene. • SFFD will notify SFDEM dispatch once PG&E resources have arrived on scene. • PG&E will determine if gas shutoff can occur on scene or at a different location. • PG&E will coordinate with SFPD for a facilitated path of travel and communicate with SFFD should the gas shutoff need to occur at a different location. • SFPD will notify SFDEM dispatch of their ETA to the location. • PG&E and SFFD will confirm all resources no longer require a facilitated path of travel and notify SFDEM dispatch. • SFPD will notify SFDEM dispatch and will be released from the incident. Additionally, PG&E revised Utility Procedure TD-6700P-03 “Gas Dispatch and Scheduling Handling 911 Calls - Emergency Response,” which became effective on 8/12/2019 and provides guidance for PG&E dispatch personnel when responding to 911 emergency response calls and when emergency escort support is needed by field crews. Based on the lessons learned from this incident and others, PG&E has a dedicated team of Emergency Response and Public Safety Specialists working to increase our collaboration with emergency services across the State of California. In 2020, PG&E's Public Safety Specialist (PSS) team responded to 658 emergencies, conducted over 90 First Responder Workshops reaching over 2,000 first responders (law enforcement, fire, Community Emergency Response Team (CERT), and public works), conducted two safety fairs reaching over 650 people, participated in 59 Community Wildlife Safety Program (CWSP) outreach engagements, and supported (nine) 811 activities.
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