NTSB Safety Recommendation P-25-009

NTSB safety recommendation P-25-009.

TO THE AMERICAN GAS ASSOCIATION: Share the details of the March 24, 2023, natural gas–fueled explosion and fire in West Reading, Pennsylvania, with your members, encouraging them to evaluate the effectiveness of their current delivery methods of public awareness programs and to promote the installation of natural gas alarms in businesses, residences, and other places of congregation that they serve.

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: American Gas Association

Addressee Status: Open - Acceptable Response

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2025-04-08

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 assist victims and their family members affected by major transportation disasters. We are providing the following information to urge the American Gas Association 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 also includes information about our 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 the American Gas Association (additional information regarding this recommendation can be found in the noted section of the report): • Share the details of the March 24, 2023, natural gas–fueled explosion and fire in West Reading, Pennsylvania, with your members, encouraging them to evaluate the effectiveness of their current delivery methods of public awareness programs and to promote the installation of natural gas alarms in businesses, residences, and other places of congregation that they serve. (P-25-9) (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 (Safety Recommendation P-25-9). 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. All communications regarding safety recommendations are 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. In the likely event that your organization uses auto generated and/or preformatted confidentiality statements on letterhead or outgoing e-mails, please include a statement in your letter indicating that the information can be publicly released. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov. 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 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 (for example, P-25-9). 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

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2025-07-07

Communication Type: Official Correspondence

Communication Contents: -From Karen A. Harbert, President and Chief Executive Officer, American Gas Association: The American Gas Association (AGA) commends the work that the National Transportation Safety Board (“NTSB”) performs in the interest of public safety. In past accident investigations, the NTSB has provided several astute recommendations to the natural gas industry which have truly advanced public safety. AGA represents more than 200 local natural gas distribution companies that deliver natural gas safely, reliably, and responsibly to homes and businesses. There are more than 79 million residential, commercial, and industrial natural gas customers in the U.S., of which 94 percent — more than 74 million customers — receive their gas from AGA members. The safe transmission and distribution of natural gas is the highest priority of AGA and its members. In its final report (NTSB Pipeline Investigation Report PIR-25-01, dated March 18, 2025) on the West Reading, PA natural gas-fueled explosion and fire, the NTSB recommended the American Gas Association (AGA) to: Share the details of the March 24, 2023, natural gas–fueled explosion and fire in West Reading, Pennsylvania, with your members, encouraging them to evaluate the effectiveness of their current delivery methods of public awareness programs and to promote the installation of natural gas alarms in businesses, residences, and other places of congregation that they serve. On April 8, 2025, AGA staff sent an email summary of the report to AGA member companies representatives, including VP-level operations and engineering leadership, pipeline safety compliance subject matter experts, field operations leaders, as well as personnel responsible for customer field services, measurement, and regulation. The AGA summary included access to NTSB’s West Reading investigation website, access to (and attachment of) the final report, the NTSB’s findings, and the full text of Recommendation P-25-9. Report details were subsequently shared at various AGA committee meetings, including its annual Operations Conference and spring committee meetings held in Aurora, Colorado on May 5-8, 2025. Natural gas utility operations leaders and subject matter experts from across the country attended AGA’s spring meetings and were again encouraged to review the March 18, 2025 report within their own organization. AGA is grateful that NTSB’s Pipeline Investigator Kim West provided two presentations that week and highlighted the findings of the West Reading accident report to the AGA members. Safety is paramount to AGA and its members as demonstrated by the above-referenced evaluation of the report the lessons gained from the West Reading Incident. AGA members routinely evaluate the effectiveness of their public awareness programs, often using information from AGA forums to support their efforts. AGA recognizes that natural gas alarms can be a useful tool to help building occupants identify the presence of natural gas. However, odorant, the pungent and memorable smell of rotten eggs, remains the primary means of detecting the presence of combustible levels of natural gas in businesses, residences, and other places of human congregation. Natural gas alarms may complement but do not replace odorization as the most effective means of identifying the presence of natural gas. The potential safety benefits of natural gas alarms, as well as their reliable performance, are based upon many considerations, including, but not limited to, the configuration of the premises, air flow, proper installation and maintenance in accordance with manufacturer instructions, and compliance with relevant local code requirements. Unlike odorant, these factors are outside the jurisdiction and control of natural gas distribution utilities. Indeed, many members educate and inform their customers of the availability of methane detectors, however there remains some concern regarding reliable performance of these devices based on the considerations noted above. It is precisely for this reason that other in-home/in-building safety devices such as smoke alarms and carbon monoxide alarms are included in life safety, fire safety, and building construction national consensus standards. These standards are developed by subject matter experts and incorporated by reference into state and municipal codes. AGA understands the NTSB’s focus on natural gas detectors and will send additional communications to its member companies, providing them an update on how voluntary consensus standards are addressing natural gas alarms and to encourage members to consider whether, when, and how to communicate the potential safety benefits of natural gas alarms when installed and maintained consistent with manufacturer and local code requirements. To further this commitment, NFPA 715, Standard for the Intallation of Fuel Gases Detection and Warning Equipment, is the national consensus standard that directly addresses natural gas alarms. It includes provisions addressing installation, power source, and maintenance of natural gas alarms, among other issues. AGA is a member of the consensus committee that developed NFPA 715 and voted to approve the prior version, NFPA 715 (2023), and the most recently published version, NFPA 715 (2026). NFPA 715 has been proposed for incorporation by reference into model codes addressing life safety, fire safety, and building construction. These codes are developed to improve building and occupant safety and are relied upon by builders, plumbers, and electricians when constructing or renovating buildings. State and municipal authorities adopt these codes to help ensure the buildings and building occupants in their jurisdictions are safe, and state and municipal building inspectors rely on these codes when enforcing building construction requirements. Once natural gas alarms are more widely adopted by state and municipal life safety, fire safety, and building codes, natural gas alarms will likely be more commonly used. AGA will continue to engage in voluntary national consensus standards that develop model life safety, fire safety, building construction, and natural gas alarm installation standards, which are currently addressing the safe and effective use of natural gas alarms in commercial buildings and residences.

Addressee Acronym: AGA

Addressee Organization Type: A-Associations

Communication Date: 2025-12-08

Communication Type: Official Correspondence

Communication Contents: We believe that messages about the benefits of natural gas alarms are critically important and could save lives when natural gas alarms are installed. We issued this recommendation because the natural gas industry can play a key role in shaping the effectiveness of public awareness program delivery methods so that people are better informed, both about natural gas hazards and the need for natural gas alarms. We acknowledge that adding odorant is currently the primary means of detecting the presence of natural gas in occupied buildings. However, odorant does not always alert people to the presence of natural gas. Some people cannot smell it, are sleeping when a leak occurs and are therefore unaware of an odor, do not know that the odorant is associated with natural gas, or are not in the part of the building where the natural gas is accumulating. Additionally, odorant can be stripped out of the gas, leaving it odorless again, if the natural gas migrates through soil before entering a building. As a result of this investigation, we have issued recommendations to the National Fire Protection Association and the International Code Council to revise the relevant standards to require the installation of natural gas alarms in buildings where natural gas is used. We understand the AGA emailed a summary and a copy of the West Reading report to senior leadership representatives of member companies and appreciate the opportunity for NTSB staff to speak directly with your members at the AGA’s annual Operations Conference. We note the AGA’s plans to send additional communications to members, providing operators with options on how to communicate the safety benefits of natural gas alarms in occupied buildings. Pending our review of these communications, the Board has voted to classify Safety Recommendation P-25-9 OPEN-- ACCEPTABLE RESPONSE. Please update us at ExecutiveSecretariat@ntsb.gov on your progress toward implementing this recommendation, and do not submit both an electronic and a hard copy of the same response.