# NTSB Safety Recommendation P-25-016

- **operation:** document
- **citation:** P-25-016
- **title:** NTSB Safety Recommendation P-25-016
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 2025-04-08
- **effective on:** 2025-04-08
- **summary:** TO THE NATIONAL FIRE PROTECTION ASSOCIATION: Revise the appropriate nationally adopted building or fire codes to provide for natural gas emergency procedures.
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- **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-25-016
**body:**

NTSB safety recommendation P-25-016.

TO THE NATIONAL FIRE PROTECTION ASSOCIATION: Revise the appropriate nationally adopted building or fire codes to provide for natural gas emergency procedures.

Priority: CLASS II

Overall Status: Open - Initial Response Received

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: National Fire Protection Association

Addressee Status: Open - Initial Response Received

Addressee Acronym: NFPA

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 National Fire Protection Association 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 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 recommendations to the National Fire Protection Association (additional information regarding these recommendations can be found in the noted sections of the report): • Revise National Fire Protection Association 54 (the National Fuel Gas Code) to provide for required installation of natural gas alarms that meet the specifications of National Fire Protection Association 715 for buildings that use natural gas. (P-25-15) (See section 2.5.1.) • Revise the appropriate nationally adopted building or fire codes to provide for natural gas emergency procedures. (P-25-16) (See section 2.5.2.) 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-25-15 and -16). 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 these recommendations. 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 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-25-15 and P-25-16). 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 ga

Addressee Acronym: NFPA

Addressee Organization Type: A-Associations

Communication Date: 2025-07-07

Communication Type: Official Correspondence

Communication Contents: -From Christian Dubay, P.E., Vice President and Chief Engineer: This correspondence is in response to NTSB Safety Recommendations P-25-15 and P-25-16, in which the NTSB recommended that the NFPA, “revise National Fire Protection Association 54 (the National Fuel Gas Code) to provide for required installation of natural gas alarms that meet the specifications of National Fire Protection Association 715 for buildings that use natural gas” and “revise the appropriate nationally adopted building or fire codes to provide for natural gas emergency procedures.” We would like to provide an update on our efforts towards addressing these recommendations. As you may know, Technical Committees serve as the principal consensus bodies responsible for developing and updating all NFPA codes and standards. In order to address the NTSB recommendations, Laura Moreno, Standards Lead, Industrial and Chemical Safety, has worked with NTSB staff to ensure that these recommendations have been introduced into the standards development process for NFPA 1, NFPA 101, NFPA 5000, and NFPA 54. On June 4, Laura presented these recommendations to the NFPA 1 Building Systems and Special Occupancies (FCC-OCP) Technical Committee, and NTSB staff will present these recommendations to the following committees (responsible for NFPA 101, NFPA 5000, and NFPA 54) this summer and fall: • Building Service and Fire Protection Equipment (BLD/SAF-BSF): 7-18-25 • Residential Occupancies (BLD/SAF-RES): 7-22-25 • Assembly Occupancies (BLD/SAF-AXM): 7-22-25 • Educational and Day-Care Occupancies (BLD/SAF-END): 7-23-25 • Health Care Occupancies (BLD/SAF-HEA): 7-23-25 • Industrial, Storage, and Miscellaneous Occupancies (BLD/SAF-IND): 7-23-25 • Board and Care Facilities (BLD/SAF-BCF): 7-24-25 • Mercantile and Business Occupancies (BLD/SAF-MER): 7-24-25 • Detention and Correctional Occupancies (BLD/SAF-DET): 7-28-25 • National Fuel Gas Code (NFG-AAA): 10-7-25 – 10-9-25 After these Technical Committees have met and have considered the NTSB recommendations, we will provide another update. In the meantime, any questions or comments can be directed to Laura Moreno, Standards Lead, Industrial and Chemical Safety. We look forward to continued open communication and the opportunity to work with the NTSB towards a shared safety mission.
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