NTSB Safety Recommendation P-25-010

NTSB safety recommendation P-25-010.

TO THE AMERICAN PETROLEUM INSTITUTE: Review the findings and plan from the Pipeline and Hazardous Materials Safety Administration’s actions on P 25 3 and update your Recommended Practice 1162 to provide specific guidance to natural gas distribution pipeline operators on effective safety communication with people who live, work, or congregate within the coverage area of a natural gas distribution pipeline system.

Priority: CLASS II

Overall Status: Open - Await 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 Petroleum Institute

Addressee Status: Open - Await Response

Addressee Acronym: API

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 Petroleum Institute 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 Petroleum Institute (additional information regarding this recommendation can be found in the noted section of the report): • Review the findings and plan from the Pipeline and Hazardous Materials Safety Administration’s actions on P-25-3 and update your Recommended Practice 1162 to provide specific guidance to natural gas distribution pipeline operators on effective safety communication with people who live, work, or congregate within the coverage area of a natural gas distribution pipeline system. (P-25-10) (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-25-10). 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-25-10). 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. 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 natural gas transmission pipeline rupture in San B