# NTSB Safety Recommendation P-83-038 - **operation:** document - **citation:** P-83-038 - **title:** NTSB Safety Recommendation P-83-038 - **source type:** guidance - **agency:** National Transportation Safety Board - **status:** guidance - **official:** true - **published on:** 1984-01-17 - **effective on:** 1984-01-17 - **summary:** THE NTSB RECOMMENDS THAT THE AMERICAN GAS ASSOCIATION AND THE INTERSTATE NATURAL GAS ASSOCIATION OF AMERICA: NOTIFY ITS MEMBER COMPANIES OF THE CIRCUMSTANCES OF THE ACCIDENT IN BLOOMFIELD, NEW MEXICO, ON MAY 26, 1983, AND URGE THEM TO EMPHASIZE TO THEIR MAINTENANCE EMPLOYEES THE IMPORTANCE OF BOLT TIGHTENING PROCEDURES, THE CORRECT SEQUENCE OF BOLT TIGHTENING, AND THE HAZARDS OF TIGHTENING BOLTS UNDER PRESSURE. - **machine formats:** - **json:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-83-038.json - **markdown:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-83-038.md - **app url:** https://regulus.evalyn.ai/document/ntsb-recommendation-p-83-038 - **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-83-038 **body:** NTSB safety recommendation P-83-038. THE NTSB RECOMMENDS THAT THE AMERICAN GAS ASSOCIATION AND THE INTERSTATE NATURAL GAS ASSOCIATION OF AMERICA: NOTIFY ITS MEMBER COMPANIES OF THE CIRCUMSTANCES OF THE ACCIDENT IN BLOOMFIELD, NEW MEXICO, ON MAY 26, 1983, AND URGE THEM TO EMPHASIZE TO THEIR MAINTENANCE EMPLOYEES THE IMPORTANCE OF BOLT TIGHTENING PROCEDURES, THE CORRECT SEQUENCE OF BOLT TIGHTENING, AND THE HAZARDS OF TIGHTENING BOLTS UNDER PRESSURE. Priority: CLASS II Overall Status: Closed - Acceptable Action Issued Date: 1984-01-17 Adopted Date: 1983-12-12 Overall Date Closed: 2001-04-05 Synopsis: ON MAY 26, 1983, NATURAL GAS AT 815 POUNDS/SQUARE INCH GAGE (PSIG) BEGAN TO ESCAPE THROUGH A FAILED GASKET IN A COMPRESSOR AT THE EL PASO NATURAL GAS COMPANY'S BLANCO GASOLINE PLANT NEAR BLOOMFIELD, NEW MEXICO. THE COMPRESSOR STATION OPERATOR HEARD A LOUD NOISE, RAN TO THE VALVE MANIFOLD OUTSIDE THE COMPRESSOR BUILDING, AND TRIED TO SHUT OFF THE GAS SUPPLY TO COMPRESSOR NO. 14. ANOTHER EMPLOYEE, WHO ALSO HEARD THE NOISE, RAN INTO THE COMPRESSOR BUILDING AND TRIED TO SHUT DOWN THE COMPRESSOR ENGINE. BEFORE EITHER PERSON SUCCEEDED, THE ESCAPING GAS IGNITED, EXPLODED, AND BURNED. THE TWO EMPLOYEES WERE BURNED SEVERELY, ONE COMPRESSOR WAS DESTROYED, ANOTHER COMPRESSOR WAS DAMAGED, THE WINDOWS AND DOORS OF THE COMPRESSOR BUILDING WERE BLOWN OUT, AND OTHER STRUCTURAL DAMAGE RESULTED. Probable Cause: The probable cause was the improper tightening of compressor head bolts, which caused a compressor head gasket to rupture and release natural gas that ignited; contributing factors were El Paso’s lack of proper bolt-tightening procedures and maintenance training, and inadequate emergency-procedure training that delayed blowdown and extended the emergency. Ntsbnumber: DCA83MP019 Report Number: PAR-83-04 Addressee Name: Interstate Natural Gas Association of America Addressee Status: Closed - Unacceptable Action Addressee Date Closed: 2001-04-05 Addressee Acronym: INGAA Addressee Organization Type: A-Associations Communication Date: 1984-01-20 Communication Type: Official Correspondence Communication Contents: INGAA LETTER: ENCLOSED FOR YOUR INFORMATION IS A COPY OF THE MEMO TO INGAA'S MEMBERSHIP NOTIFYING THEM OF NTSB'S RECOMMENDATIONS P-83-38 THROUGH -40. ADDITIONALLY, AS HAS BEEN INGAA'S POLICY IN THE PAST, THESE RECOMMENDATIONS WILL BE AGENDA ITEMS AT THE NEXT INGAA PIPELINE SAFETY AND CONSTRUCTION AND OPERATIONS COMMITTEE MEETINGS. Addressee Acronym: INGAA Addressee Organization Type: A-Associations Communication Date: 1984-04-30 Communication Type: Official Correspondence Communication Contents: On April 30, 1984, based on information provided in the INGAA letter of January 20, 1984, indicating that the Board’s recommendations were scheduled for discussion at the next INGAA pipeline committee meeting, Safety Recommendations P-83-38 through -40 were classified “Open-Acceptable Response.” Because the Safety Board has received no further response from INGAA on these issues, Safety Recommendations P-83-38 through -40 are classified “Closed-Unacceptable Action.” Addressee Acronym: INGAA Addressee Organization Type: A-Associations Communication Date: 2000-08-08 Communication Type: Official Correspondence Communication Contents: ON 4/30/84, BASED ON INFORMATION PROVIDED IN THE INGAA LETTER OF 1/20/84, P-83-38 THROUGH -40 WERE CLASSIFIED "OPEN--ACCEPTABLE RESPONSE." TO DATE THE SAFETY BOARD HAS HAD NO FURTHER RESPONSE FROM INGAA, AND WE WOULD APPRECIATE LEARNING WHAT ACTION HAS BEEN TAKEN TO IMPLEMENT THESE RECOMMENDATIONS. Addressee Acronym: INGAA Addressee Organization Type: A-Associations Communication Date: 2001-04-05 Communication Type: Official Correspondence Communication Contents: On April 30, 1984, based on information provided in the INGAA letter of January 20, 1984, indicating that the Board’s recommendations were scheduled for discussion at the next INGAA pipeline committee meeting, Safety Recommendations P-83-38 through -40 were classified “Open--Acceptable Response.” Because the Safety Board has received no further response from INGAA on these issues, Safety Recommendations P-83-38 through -40 are classified “Closed--Unacceptable Action.” Addressee Name: American Gas Association Addressee Status: Closed - Acceptable Action Addressee Date Closed: 1985-01-11 Addressee Acronym: AGA Addressee Organization Type: A-Associations Communication Date: 1984-07-20 Communication Type: Official Correspondence Communication Contents: AGA LETTER: THE RECOMMENDATION APPEARS TO GO INTO TOO MUCH DETAIL. THE A.G.A. SUGGESTS THAT THE RECOMMENDATION SHOULD READ "...AND URGE THEM TO EMPHASIZE TO THEIR OPERATING AND MAINTENANCE EMPLOYEES THE IMPORTANCE OF PROPER BOLT TIGHTENING PROCEDURES." DURING THE FOURTH QUARTER OF 1983, THE A.G.A. PUBLISHED AN OPERATING SECTION ENGINEERING TECHNICAL NOTE (CPR 83-4-1), THREADED FASTENERS TORQUING. THIS TECHNICAL NOTE PREPARED BY THE COMPRESSOR COMMITTEE PERTAINS TO PROPER SELECTION, INSTALLATION, AND MAINTENANCE OF THREADED FASTENERS USED TO SECURE GAS COMPRESSORS AND ENGINES. IT IS AVAILABLE FROM A.G.A. HEADQUARTERS TO ANY MEMBER COMPANY DESIRING A COPY. THE TECHNICAL NOTE IS THE GUIDELINE REFERRED TO ON PAGE 2, PARAGRAPH 3, OF THE NTSB SAFETY RECOMMENDATION. Addressee Acronym: AGA Addressee Organization Type: A-Associations Communication Date: 1985-01-11 Communication Type: Official Correspondence Communication Contents: WE WELCOME YOUR SUGGESTIONS FOR CLARIFYING OR EMPHASIZING TO YOUR MEMBER COMPANIES THE ISSUES ADDRESSED IN THE BOARD'S SAFETY RECOMMENDATIONS. IN THAT REGARD, WE UNDERSTAND THAT ENGINEERING TECHNICAL NOTE CPR 83-4-1 PERTAINS TO THE PROPER SELECTION, INSTALLATION, AND MAINTENANCE OF THREADED FASTENERS USED TO SECURE GAS COMPRESSORS AND ENGINES. YOUR EFFORTS TO NOTIFY MEMBER COMPANIES OF THE AVAILABILITY OF THIS TECHNICAL NOTE SATISFY THE INTENT OF THIS RECOMMENDATION, AND P-83-38 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION." - **truncated:** false - **body characters:** 6008