NTSB Safety Recommendation P-25-004

NTSB safety recommendation P-25-004.

TO THE OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION: Require employers whose facilities use natural gas to implement natural gas emergency procedures.

Priority: CLASS II

Overall Status: Open - Unacceptable 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: United States Department of Labor, Occupational Safety and Health Administration

Addressee Status: Open - Unacceptable Response

Addressee Acronym: OSHA

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 recommendation to OSHA. Additional information regarding this recommendation can be found in the noted section of the report. • Require employers whose facilities use natural gas to implement natural gas emergency procedures. (P 25 4) (See section 2.5.2.) 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 (Safety Recommendation P-25-4). 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 March 18, 2025, 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 recommendation by number (for example, P-25-4). 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: 2.5.2 Companies’ Emergency Response Procedures As a private company, Palmer is regulated by OSHA under its authority to set health and safety standards for private-sector employers. Emergencies can be either natural or manmade, and some can be anticipated and planned for. Emergency response procedures can reduce serious injury or loss of life. OSHA does not have an occupational safety and health standard requiring natural gas emergency response procedures, however. During its postaccident inspection of the March 24 incident, OSHA issued several citations to Palmer. None of the regulations cited would have required the company to have an emergency response plan that addresses natural gas hazards. According to the American Gas Association, about 5.6 million businesses receive natural gas service. As with Palmer, businesses with natural gas service are not required by OSHA to have an emergency response procedure for a gas leak or related training for employees. Palmers’ Red Book had no procedures that addressed natural gas emergencies. Palmer had consulted federal and state agency guidance as well as the NFPA when developing the Red Book. The Red Book addressed other procedures and safety measures required by OSHA—for example, evacuation routes and documentation of fatalities and serious injuries—so it is likely that the company would have included natural gas emergency response procedures had these been required. As seen in this accident, companies may not recognize a natural gas leak as a serious hazard that needs to be addressed in their emergency response procedures. There are no requirements for natural gas emergency response procedures in the IFGC, which Pennsylvania has adopted. A federal requirement mandating workplace natural gas emergency response procedures could prevent a similar accident to the one in this report. The NTSB concludes that when businesses that use natural gas do not have natural gas emergency procedures and training, employees may be unaware or unsure of the steps they should take if they smell natural gas, thus placing them at risk should a leak occur. With no OSHA regulation specifically requiring an emergency response procedure for natural gas leaks, companies lack official direction on how to protect their workers from natural gas hazards in their buildings. Therefore, the NTSB recommends that OSHA require employers whose facilities use natural gas to implement natural gas emergency procedures. After the accident, Palmer developed natural gas emergency response procedures and workplace safety trainings in both English and Spanish, addressing the safety issue of delayed evacuation during a natural gas leak. An emergency response procedure can prepare building occupants to respond if a natural gas leak occurs or if a natural gas alarm sounds. Neither of the fuel gas codes—the IFGC, which Pennsylvania has adopted, and NFPA 54, which other states have adopted—contain requirements for natural gas emergency response procedures. The IFC (the fire code adopted by Pennsylvania) requires a fire safety and evacuation plan, but it is not specific to natural gas; similarly, the NFPA fire code (NFPA 1) also does not contain a natural gas–specific emergency procedure. Model codes like the IFC, IFGC, NFPA 1, and NFPA 54 incorporate consensus standards to protect against hazardous conditions. The code development process is participatory and transparent, establishing broadly accepted code requirements that are adapted and adopted by state and local jurisdictions. The NTSB thus concludes that the consensus-based nature and wide reach of the model codes, such as building or fire codes, make them effective instruments to address natural gas–related risks to employees of businesses that use natural gas. Although these codes may include the fuel gas codes IFGC and NFPA 54, other codes such as the fire codes may be appropriate locations for natural gas emergency response procedures. As noted earlier, the ICC administers the IFC and IFGC. Therefore, the NTSB recommends that the ICC revise the appropriate nationally adopted building or fire codes to provide for natural gas emergency procedures. The NTSB likewise recommends that the NFPA revise the appropriate nationally adopted building or fire codes to provide for natural gas emergency procedures.

Addressee Acronym: OSHA

Addressee Organization Type: G-Federal Government

Communication Date: 2025-09-26

Communication Type: Official Correspondence

Communication Contents: -From Amanda Wood Laihow, Acting Assistant Secretary: We appreciate and share your concern about protecting workers from hazards faced with natural gas-related emergencies. OSHA typically uses national consensus standards as a model for developing and updating OSHA standards, consistent with the National Technology Transfer and Advancement Act of 1995. Industry consensus standards also serve as evidence that a hazard is recognized and that there is a feasible means of correcting such a hazard, which could support violations of OSHA's General Duty Clause. The Agency maintains a regulatory agenda that reflects the administration’s priorities for our limited resources. We cannot commit to new rulemaking at this time. However, OSHA agrees that natural gas hazards are worth recognition. The Agency will closely follow any developments from the American Petroleum Institute, International Code Council, and National Fire Protection Association in response to recommendations P-25-10, P-25-13, P-25-14, P-25-15, and P-25-16 and will try to assist in proliferating newly developed guidance and codes. In this case, R.M. Palmer accepted a violation of 29 CFR 1910.38(f)(2) during settlement and committed to implementing natural gas leak procedures.

Addressee Acronym: OSHA

Addressee Organization Type: G-Federal Government

Communication Date: 2026-04-22

Communication Type: Official Correspondence

Communication Contents: Our investigation found that Palmer consulted federal and state agency guidance as well as the NFPA when developing its emergency plan manual (The Red Book). The Red Book addressed other OSHA-required procedures and safety measures, like evacuation routes and how to document fatalities and serious injuries, so we believe it would likely have also included natural gas emergency response procedures had they been required. We acknowledge that the National Technology Transfer and Advancement Act of 1995 directs federal agencies and departments to use technical standards developed by voluntary consensus bodies, unless impractical or inconsistent with applicable law. However, we point out that does not absolve OSHA, as the regulator for workplace health and safety, from setting the minimum standard for natural gas emergency procedures. You wrote that OSHA’s regulatory agenda reflects the administration’s priorities for the agency’s limited resources; therefore, OSHA cannot commit to taking the recommended action at this time. Instead, you will try to help proliferate any new guidance and codes developed by the relevant code committees. Although we also issued recommendations to states, industry groups, and code committees as a result of this investigation, we have found that code committees are reluctant to add a requirement without regulation, and states are reluctant to regulate in areas lacking an industry standard. We encourage you to take the lead and require employers whose facilities use natural gas to implement natural gas emergency procedures. Pending that action, the Board has voted to classify Safety Recommendation P-25-4 OPEN-- UNACCEPTABLE RESPONSE.