# NTSB Safety Recommendation P-25-018 - **operation:** document - **citation:** P-25-018 - **title:** NTSB Safety Recommendation P-25-018 - **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 R.M. PALMER COMPANY: Revise your natural gas emergency procedure to direct all employees to immediately evacuate upon smelling natural gas odorant and to specify a safe evacuation location. - **machine formats:** - **json:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-25-018.json - **markdown:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-25-018.md - **app url:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-25-018 - **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-25-018 **body:** NTSB safety recommendation P-25-018. TO THE R.M. PALMER COMPANY: Revise your natural gas emergency procedure to direct all employees to immediately evacuate upon smelling natural gas odorant and to specify a safe evacuation location. 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: R.M. Palmer Company Addressee Status: Open - Await Response Addressee Organization Type: P-Private Industry 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 R.M. Palmer Company 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 R.M. Palmer Company (additional information regarding this recommendation can be found in the noted section of the report): • Revise your natural gas emergency procedure to direct all employees to immediately evacuate upon smelling natural gas odorant and to specify a safe evacuation location. (P-25-18) (See section 2.2.2.) 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-25-18). 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 company 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-25-18). 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: 2.2.2 Delayed Evacuation At Palmer’s facilities in West Reading, natural gas was used for the Building 2 basement heating system, the boiler for the steam heat system, and a backup generator. In interviews with the NTSB, Palmer management characterized the risk associated with a natural gas leak as “low” because they had few natural gas–fired appliances at that location. The perception was that the possibility of any natural gas leak would therefore be relatively minimal. The company’s emergency plan manual, the Red Book, listed UGI’s emergency number and contained floor plans with utility shut-off locations but lacked a procedure for when to use the number or how to shut off the gas. The company’s crisis management plan listed various potential threats to business operations but did not include a natural gas emergency in this list. Likewise, the Red Book contained procedures on how to respond to some of these threats but not to natural gas. Palmer did not provide employee training on natural gas hazards and how to respond to the smell of gas. The flammable and explosive hazards of natural gas have long been recognized by the pipeline industry. To reduce the chances that natural gas leaks will go undetected, federal regulations require the addition of an odorant to natural gas distribution pipelines. General best practices for when natural gas is detected are to immediately evacuate to a safe distance and then call either the gas operator or 9 1 1. For example, UGI’s website instructs anyone smelling a gas odor to “act fast” and leave the area and call UGI, 9 1 1, or both. Employees working in both Buildings 1 and 2—and some outside of the buildings—recalled smelling gas or a strange odor on the afternoon of March 24, 2023. In interviews with the NTSB, many Palmer employees stated that they knew that the distinctive sulfurous odor indicated natural gas, but others recalled expressing initial confusion as to what the smell was. Some employees asked their supervisors for guidance but were not told to evacuate; one employee in Building 1 and another in Building 2 self-evacuated. Witness accounts and surveillance camera data indicated that many employees in Building 2 at the time of the accident had been aware of the gas smell at least 13 minutes before the explosion. None of the employees that were aware of the natural gas odor pulled the fire alarm when it was detected, and Palmer management did not issue an evacuation order. Palmer’s CEO told the NTSB that employees were empowered to evacuate for safety reasons. 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