NTSB Safety Recommendation P-25-003

NTSB safety recommendation P-25-003.

TO THE PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION: Identify effective means for natural gas distribution pipeline operators to communicate with people who live, work, or congregate within the coverage area of a natural gas distribution pipeline system and implement a plan to help operators drive continuous improvement in public awareness of natural gas safety.

Priority: CLASS II

Overall Status: Open - Acceptable Response

Issued Date: 2025-04-08

Adopted Date: 2025-03-18

Synopsis: This report discusses the March 24, 2023, natural gas–fueled explosion and fire at Building 2 of the R.M. Palmer Company, a candy manufacturer located in West Reading, Pennsylvania. The explosion destroyed the manufacturer’s Building 2 and caused significant structural damage to its adjacent Building 1 and other surrounding structures. In total, 7 people were killed, 10 people were injured, and 3 families were displaced from a neighboring apartment building. Safety issues identified in this report include degradation of a retired service tee, insufficient consideration of threats to pipeline integrity, the risk associated with unmarked private pipeline assets crossing public rights-of-way (for example, a public street), delayed evacuation of Building 2 despite detection of natural gas, natural gas safety messaging that may not reach certain members of the public, insufficient guidance on gas leak emergency procedures, absence of natural gas detection alarms in commercial buildings, and insufficient accessibility of gas distribution line valves. As part of this investigation, the National Transportation Safety Board issued recommendations to the Pipeline and Hazardous Materials Safety Administration, the Occupational Safety and Health Administration, 50 states along with the Commonwealth of Puerto Rico and the District of Columbia, the Commonwealth of Pennsylvania, the Pennsylvania Public Utility Commission, the American Gas Association, the American Petroleum Institute, the Gas Piping Technology Committee, the Common Ground Alliance, the International Code Council, the National Fire Protection Association, UGI Corporation, and R.M. Palmer Company.

Probable Cause: The National Transportation Safety Board determines that the probable cause of the explosion was degradation of a retired 1982 Aldyl A polyethylene service tee with a Delrin polyacetal insert that allowed natural gas to leak and migrate underground into the R.M. Palmer Company candy factory buildings, where it was ignited by an unknown source. Contributing to the degradation of the service tee and insert were significantly elevated ground temperatures from steam escaping R.M. Palmer Company’s corroded underground steam pipe, located near the service tee, that had been unmarked and cracked. Contributing to the steam pipe crack was soil movement and R.M. Palmer Company’s lack of awareness of the pipe’s corroded state. Contributing to the natural gas leak was UGI Corporation’s lack of awareness of the nearby steam pipe, which led to an incomplete integrity management program evaluation that did not consider or manage the risk posed by the steam pipe. Contributing to the accident’s severity was R.M. Palmer Company’s insufficient emergency response procedures and training of its employees, who did not understand the hazard and did not evacuate the buildings before the explosion.

Ntsbnumber: PLD23LR002

Report Number: PIR-25-01

Addressee Name: PHMSA

Addressee Status: Open - Acceptable Response

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2026-03-26

Communication Type: Recommendation Reiteration

Communication Contents: From the Report, “Atmos Energy Corporation Natural Gas-Fueled Home Explosions and Fires Jackson, Mississippi, January 24, 2024, and January 27, 2024” published on March 26, 2026. Ineffective Public Awareness Program Public Awareness Program Effectiveness Affected Public Atmos’s public awareness program’s effectiveness scores indicated that about 62% of the affected public within Atmos distribution areas, including areas in Mississippi, knew that they should leave the area and then call 9-1-1 or the gas company during a suspected natural gas leak. About 37% of those surveyed were unaware of how to safely respond to a suspected natural gas leak. Footnote: As discussed in section 1.9.2, survey percentages are not complete (do not total 100%), likely because of rounding or incomplete responses. Atmos’s public awareness program communication plan required the operator to educate members of the affected public (customers and noncustomers) on safety topics that included how to respond to a suspected natural gas leak. Atmos’s plan required the operator to communicate to customers twice a year and noncustomers once a year through delivery channels such as bill inserts (for customers) and television (for customers and noncustomers). However, several people smelled natural gas odorant before the accidents occurred but were unaware of pipeline safety guidance to respond to the smell of natural gas odorant by evacuating and then immediately calling 9-1-1 or the gas company (Atmos in this case). According to NTSB and Mississippi Public Service Commission interviews, at least three people smelled natural gas odorant on Bristol Boulevard before the accident and were unaware of the need to immediately report it, and at least two people smelled natural gas odorant on Shalimar Drive before the accident and were unaware of the need to immediately report it. Thus, Atmos’s public awareness program was ineffective at educating the public. In addition to this investigation, several NTSB investigations in the last 15 years have determined that the natural gas distribution operator’s public awareness program was a factor in the accident. For example, the NTSB’s Birmingham, Alabama, investigation of an accident that resulted in one fatality and three injuries determined that residents had smelled natural gas odorant 2 weeks before the explosion but had not informed the gas company or local authorities (NTSB 2016). In addition, the NTSB’s New York City, New York, investigation of an accident that resulted in 8 fatalities, over 50 injuries, and the displacement of 100 families from their homes determined that the operator’s public awareness program did not effectively inform customers and the public about both the importance of reporting the smell of natural gas odorant and the number to call to report the smell of odorant (NTSB 2015). Similarly, the NTSB’s San Bruno, California, investigation of an accident that resulted in eight fatalities and many more injuries determined that the operator’s public awareness program had left the affected public unaware of pipeline safety (NTSB 2011). Therefore, the NTSB concludes that in the accidents in Jackson, Mississippi, and in several natural gas accidents that the NTSB has investigated, the operator’s public awareness program was ineffective at educating the public on how to safely respond to the smell of natural gas odorant. In March 2023, the NTSB investigated a natural gas-fueled explosion and fire that occurred in West Reading, Pennsylvania, which resulted in 7 fatalities, 10 injuries, a destroyed building, and the displacement of 3 families from a neighboring apartment building (NTSB 2025). In the West Reading accident, the NTSB determined that natural gas distribution operators have ample room and ability to improve upon their public communications regarding natural gas safety. As a result, the NTSB recommended that PHMSA: Identify effective means for natural gas distribution pipeline operators to communicate with people who live, work, or congregate within the coverage area of a natural gas distribution pipeline system and implement a plan to help operators drive continuous improvement in public awareness of natural gas safety. (P-25-3) Footnote: Safety Recommendation P-25-3 is currently classified Open—Acceptable Response. In September 2025, during a meeting with the NTSB, PHMSA reported that it had created a working group with the Pipeline Association for Public Awareness to develop strategies to improve public awareness of natural gas safety. Footnote: The Pipeline Association for Public Awareness is a nonprofit corporation that provides pipeline safety and emergency preparedness information to residents, businesses, farmers, excavators, emergency responders, and public officials. PHMSA also agreed to work with stakeholders, such as the American Petroleum Institute and state partners, to address Safety Recommendation P-25-3. Notwithstanding the previous NTSB investigations in which an ineffective natural gas distribution operator public awareness program was a factor in the accident, including the West Reading investigation, the NTSB investigation of the two Jackson accidents has again identified the need for natural gas distribution pipeline operators to effectively communicate with the affected public. Therefore, the NTSB reiterates Safety Recommendation P 25-3 to PHMSA.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2025-04-08

Communication Type: Transmittal Letter

Communication Contents: This letter provides information about the National Transportation Safety Board’s (NTSB) March 18, 2025, report, UGI Corporation Natural Gas-Fueled Explosion and Fire, West Reading, Pennsylvania, March 24, 2023, NTSB/PIR-25/01. 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: • Degradation of a retired Aldyl A service tee that was accelerated by elevated ground temperatures from a corroded and cracked steam pipe nearby. • UGI Corporation’s insufficient consideration of pipeline integrity threats, particularly Aldyl A service tees with Delrin inserts at elevated temperatures. • Presence of unmarked and unreported private assets crossing public rights-of-way, excluding them from the Pennsylvania One Call System and increasing the risk of damage to them. • Delayed evacuation of Palmer’s Building 2 despite detection of natural gas by employees and others. • Natural gas safety messaging from pipeline operator public awareness programs that may not reach certain members of the public. • Insufficient guidance on natural gas emergency procedures. • Absence of natural gas alarms in commercial buildings. • Insufficient accessibility of gas distribution line valves. 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. • Issue an advisory bulletin to all regulated natural gas distribution pipeline operators referencing distribution integrity management program regulations and encouraging operators to: • Complete a one-time inventory of all plastic assets that are located in environments that experience or are at risk of elevated temperatures; • Continue, during maintenance and new construction projects, to identify plastic assets that are in elevated temperature environments; and • Evaluate and mitigate risks to deter the degradation of these assets. (P 25 1) (See section 2.3.) • Issue an advisory bulletin that reviews the details of the March 24, 2023, natural gas–fueled explosion and fire in West Reading, Pennsylvania, and advises all regulated natural gas distribution pipeline operators to address the risk associated with Aldyl A service tees with Delrin inserts, including replacing or remediating them. (P-25-2) (See section 2.3.) • Identify effective means for natural gas distribution pipeline operators to communicate with people who live, work, or congregate within the coverage area of a natural gas distribution pipeline system and implement a plan to help operators drive continuous improvement in public awareness of natural gas safety. (P-25-3) (See section 2.5.) In addition, the NTSB reiterates the following recommendation to PHMSA: • 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 2.3.) 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 Recommendations P-25-1 through -3 and reiterated Safety Recommendation P-21-2). 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. The attached letter from the NTSB Chairman provides information about the report UGI Corporation Natural Gas-Fueled Explosion and Fire, West Reading, Pennsylvania, March 24, 2023, PIR-25-1. 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-25-1 through P-25-3). 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. From the report UGI Corporation Natural Gas-Fueled Explosion and Fire, West Reading, Pennsylvania, March 24, 2023, PIR-25-1: 2.5 Public Awareness and Preparedness Education and awareness about natural gas are critical to help organizations understand the risk to their facilities and employees and to motivate them to implement policies, procedures, and training to mitigate risks associated with natural gas hazards. For this reason, federal regulations adopted by state pipeline regulators require natural gas pipeline operators to comply with public awareness program standards outlined in API RP 1162, the first edition of which was released in 2003 and is incorporated by reference into the regulations. API RP 1162 is now in its third edition. One of the objectives of such programs is to educate the affected public on how to recognize and respond to a pipeline emergency. As described in the first edition of API RP 1162, the affected public includes people living in single- and multifamily residences as well as “places of congregation” such as businesses or schools with natural gas service. API RP 1162’s baseline communication requirement for the affected public is twice-annual bill stuffers, and these were part of UGI’s public awareness program. However, business mail that includes the gas bill and stuffers often is directed to a dedicated department at an organization (such as accounting) and not always seen by all employees. UGI also communicated safety messages through other channels, such as television, radio, newspaper, and social media, as well as community events like baseball games. Like bill stuffers, most of these are one-way communications from UGI with no guarantee that their customers received the information or paid attention to it. The NTSB has investigated accidents in which ineffective aspects of operators’ public awareness programs have led to a lack of public understanding of natural gas hazards. In 2013, we investigated the explosion of a public housing apartment in Birmingham, Alabama, when natural gas in the apartment ignited (NTSB 2016). We found that residents had smelled gas as far back as 2 weeks before the explosion but had not informed the gas company or local authorities; after the accident, the pipeline operator bolstered its dissemination of natural gas safety information to its customers. In our investigation of a 2014 apartment building explosion in New York City, we found that the operator’s public awareness programs “did not effectively inform customers and the public about both the importance of reporting a gas odor and the number to call to report a gas odor” (NTSB 2015). The NTSB’s investigation of a 2010 na

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2025-11-24

Communication Type: Official Correspondence

Communication Contents: We are aware that PHMSA has held preliminary conversations with the American Petroleum Institute and state partners to address this recommendation. Additionally, during the September 29 meeting, PHMSA staff reported the creation of a working group with the Pipeline Association for Public Awareness (PAPA), a nonprofit corporation that provides pipeline safety and emergency preparedness information to residents, businesses, farmers, excavators, emergency responders, and public officials, to develop strategies for driving continuous improvement in public awareness of natural gas safety. Pending PHMSA identifying effective ways for operators to communicate with people who live, work, or congregate near a natural gas distribution system, and implementing a plan to help drive continuous improvement in public awareness of natural gas safety, the Board has classified Safety Recommendation P-25-3 OPEN—ACCEPTABLE RESPONSE.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2025-07-01

Communication Type: Official Correspondence

Communication Contents: -From Ben Kochman, Acting Administrator: Concur. PHMSA plans to review the public awareness requirements incorporated by reference in the Federal pipeline safety regulations and to identify effective means for operators to communicate with people who live, work, or congregate near and around natural gas distribution pipelines. Once these methods are identified, PHMSA’s goal is to develop and implement a plan to help operators continually improve public awareness of natural gas safety in collaboration with the American Petroleum Institute and our State partners. PHMSA also plans to review our internal guidance for inspectors concerning public awareness program inspections to enhance the Agency's oversight of operator public awareness programs.

Addressee Acronym: PHMSA

Addressee Organization Type: G-Federal Government

Communication Date: 2026-06-04

Communication Type: Official Correspondence

Communication Contents: -From Paul J. Roberti, Administrator: PHMSA Response to Reiterated Safety Recommendation P-25-3: Concur. PHMSA published ADB-2026-05, Pipeline Safety: Preventing Excavation Damage During National Safe Digging Month and Beyond, on April 21, 2026. Footnote: PHMSA, ADB-2026-05, Pipeline Safety Preventing Excavation Damage During National Safe Digging Month and Beyond, 91 FR 21368 (Apr. 21, 2026). The ADB advises operators to expand public outreach to affected populations and establish continuous improvement practices using performance measures and stakeholder feedback. PHMSA reviewed Federal public awareness requirements and is actively engaging with the American Petroleum Institute (API) and industry stakeholders to strengthen API Recommended Practice 1162, Public Awareness Programs for Pipeline Operators. PHMSA is updating its related inspection tools, improving inspector training, and conducting targeted public awareness inspections in 2026 to evaluate operator program effectiveness. CONCLUSION PHMSA believes the planned actions described above address new NTSB Safety Recommendation P-26-2, and reiterated Safety Recommendations P-21-2 and P-25-3. We value our continued partnership with NTSB as we work to ensure the safe and reliable operation of the Nation’s pipeline transportation system and realize the President’s vision for unleashing American energy.