# NTSB Safety Recommendation P-76-028

- **operation:** document
- **citation:** P-76-028
- **title:** NTSB Safety Recommendation P-76-028
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 1976-06-23
- **effective on:** 1976-06-23
- **summary:** EXAMINE ITS PROCEDURES AND PRACTICES FOR VALVE AND PIPING CHANGES TO ASSURE THAT EACH CRITICAL ACTION IS CHECKED INDEPENDENTLY BY AT LEAST TWO PERSONS, ONE OF WHOM SHOULD BE A SUPERVISOR. (URGENT)
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- **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-76-028
**body:**

NTSB safety recommendation P-76-028.

EXAMINE ITS PROCEDURES AND PRACTICES FOR VALVE AND PIPING CHANGES TO ASSURE THAT EACH CRITICAL ACTION IS CHECKED INDEPENDENTLY BY AT LEAST TWO PERSONS, ONE OF WHOM SHOULD BE A SUPERVISOR. (URGENT)

Priority: CLASS I

Overall Status: Closed - Acceptable Action

Issued Date: 1976-06-23

Adopted Date: 1976-06-04

Overall Date Closed: 1977-07-29

Synopsis: ON JANUARY 7, 1976, EMPLOYEES AT THE MICHIGAN-WISCONSIN PIPE LINE COMPANY'S CEDARDALE, OKLAHOMA, COMPRESSOR STATION WERE DIRECTED TO OPEN A VALVE ON A SHUT-IN 12-INCH GAS-GATHERING PIPELINE IN AN ATTEMPT TO INCREASE THE FLOW INTO THE MAIN LINE. NATURAL GAS AND NATURAL GAS LIQUIDS AT 700-PSIG PRESSURE ROARED THROUGH THE VALVE, OUT THROUGH THE END OF AN OPEN 12-INCH PIPE, AND INTO A DITCH, WHERE SEVEN MEN WERE WORKING NEAR AN OPEN FLAME HEATER. THE NATURAL GAS LIQUIDS SATURATED THEIR CLOTHING AND THE HEATER SET THEM ON FIRE. FIVE MEN WERE KILLED AND TWO MEN WERE BURNED SERIOUSLY AS A RESULT OF THIS ACCIDENT.

Ntsbnumber: DCA76FP012

Report Number: None

Addressee Name: ANR Pipeline (formerly Michigan-Wisconsin Pipeline Company)

Addressee Status: Closed--No Longer Applicable

Addressee Date Closed: 1977-07-29

Addressee Acronym: ANR

Addressee Organization Type: P-Private Industry

Communication Date: 1976-08-10

Communication Type: Official Correspondence

Communication Contents: LTR. FROM MICHIGAN WISCONSIN PIPE LINE COMPANY: MICHIGAN WISCONSIN HAS EXAMINED ITS EMERGENCY PROCEDURES AND OPERATION AND MAINTENANCE PROCEDURES FOR THE PIPELINES AND COMPRESSOR STATION AND OUR PROCEDURE FOR ISOLATION OF FACILITIES NOW PROVIDES OPERATING PERSONNEL PERFORMING THE VALVING OR PIPING CHANGES WITH A WRITTEN INSTRUCTION THAT HAS BEEN REVIEWED BY AT LEAST TWO PERSONS AND APPROVED BY THE SUPERVISOR.
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