{"operation":"document","citation":"P-84-031","title":"NTSB Safety Recommendation P-84-031","source_type":"guidance","agency":"National Transportation Safety Board","status":"guidance","official":true,"published_on":"1984-08-23","effective_on":"1984-08-23","summary":"THE NTSB RECOMMENDS THAT THE WASHINGTON GAS LIGHT COMPANY: DEVELOP WRITTEN PROCEDURES DETAILING THE SEQUENCE OF ACTIONS TO BE TAKEN FOR SAFELY BYPASSING GAS FACILITIES, FOR ISOLATING SEGMENTS OF PIPELINE FROM GAS UNDER PRESSURE, AND FOR TESTING THE ADEQUACY OF ISOLATION ACTIONS BEFORE ANY WORK IS PERFORMED ON THE ISOLATED SEGMENT. INCORPORATE WITHIN THESE PROCEDURES REQUIREMENTS FOR CONDUCTING PREWORK MEETINGS TO EXP","machine_formats":{"json":"https://regulus.evalyn.ai/document/ntsb-recommendation-p-84-031.json","markdown":"https://regulus.evalyn.ai/document/ntsb-recommendation-p-84-031.md"},"app_url":"https://regulus.evalyn.ai/document/ntsb-recommendation-p-84-031","source_url":"https://data.ntsb.gov/carol-main-public/sr-details/P-84-031","body":"NTSB safety recommendation P-84-031.\n\nTHE NTSB RECOMMENDS THAT THE WASHINGTON GAS LIGHT COMPANY: DEVELOP WRITTEN PROCEDURES DETAILING THE SEQUENCE OF ACTIONS TO BE TAKEN FOR SAFELY BYPASSING GAS FACILITIES, FOR ISOLATING SEGMENTS OF PIPELINE FROM GAS UNDER PRESSURE, AND FOR TESTING THE ADEQUACY OF ISOLATION ACTIONS BEFORE ANY WORK IS PERFORMED ON THE ISOLATED SEGMENT. INCORPORATE WITHIN THESE PROCEDURES REQUIREMENTS FOR CONDUCTING PREWORK MEETINGS TO EXPLAIN THE WORK TO BE PERFORMED BY EACH EMPLOYEE.\n\nPriority: CLASS II\n\nOverall Status: Closed - Acceptable Action\n\nIssued Date: 1984-08-23\n\nAdopted Date: 1984-08-09\n\nOverall Date Closed: 1985-05-03\n\nSynopsis: ON OCTOBER 13, 1983, SEVEN EMPLOYEES OF THE WASHINGTON GAS LIGHT COMPANY WERE ASSIGNED TO PERFORM REQUIRED ANNUAL OPERATING AND MAINTENANCE INSPECTIONS ON A FLOW CONTROL VALVE AND A PRESSURE CONTROL VALVE AT ITS HERNDON GATE STATION IN FAIRFAX COUNTY, VIRGINIA. AS PART OF THE WORK TO BE DONE, THE EMPLOYEES DISCONNECTED THE GAS CONTROL SIGNAL LINE AND REMOVED THE BOLTS OF THE FLOW CONTROL VALVE BONNET BEFORE INSPECTING THE PIPE SEGMENT CONTAINING THE CONTROL VALVES TO INSURE THAT IT HAD BEEN ISOLATED AND VENTED PROPERLY. AT 10:13 A.M., WHILE TRYING TO REMOVE THE VALVE BONNET, NATURAL GAS AT ABOUT 150 PSIG BLEW THE BONNET UPWARD, AND GAS FILLED THE ENCLOSED PORTION OF THE BUILDING IN WHICH THE EMPLOYEES WERE WORKING. THE EMPLOYEES WITHIN THE STATION FLED OUTSIDE TO SAFETY; HOWEVER, THE FOREMAN REENTERED THE BUILDING. MOMENTS LATER, AT 10:18 A.M., GAS WAS IGNITED AND EXPLOSION AND FIRE, FOLLOWED DEMOLISHING THE BUILDING. THE FOREMAN WAS KILLED AND TWO EMPLOYEES RECEIVED MINOR INJURIES. THE CIRCUMSTANCES OF THIS ACCIDENT, AS WELL AS THOSE INVOLVED IN THE OCTOBER 29, 1982, ACCIDENT AT BURKE, VIRGINIA, INDICATE THE NEED FOR BETTER TRAINING OF WGL EMPLOYEES TO SUPPORT THEIR UNDERSTANDING OF PROCEDURES AND TO BE ALERT TO THE POTENTIAL CONSEQUENCES WHEN SUCH PROCEDURES ARE NOT CARRIED OUT EXPLICITLY. WHILE THE SAFETY BOARD IS PLEASED THAT WGL HAS INTENSIFIED TRAINING GIVEN TO ITS TRANSMISSION AND DISTRIBUTION DEPARTMENT EMPLOYEES, AN EQUALLY INTENSIVE EFFORT APPEARS NEEDED FOR ALL EMPLOYEES WHOSE RESPONSIBILITIES INVOLVE OPERATIONS WHEREIN A FAILURE TO UNDERSTAND OR TO FOLLOW REQUIRED SAFETY PROCEDURES MAY RESULT IN INJURIES OR DEATH TO EMPLOYEES OR THE PUBLIC.\n\nProbable Cause: None\n\nNtsbnumber: DCA84MP001\n\nReport Number: PAR-84-03\n\nAddressee Name: Washington Gas\n\nAddressee Status: Closed - Acceptable Action\n\nAddressee Date Closed: 1985-05-03\n\nAddressee Organization Type: P-Private Industry\n\nCommunication Date: 1985-01-11\n\nCommunication Type: Official Correspondence\n\nCommunication Contents: WASHINGTON GAS LIGHT COMPANY LTR: CONSISTENT WITH RECOMMENDATION P-84-031, WASHINGTON GAS COMPANY HAS INITIATED WRITTEN PROCEDURES FOR HIGH-RISK AREAS SUCH AS THE HERNDON GATE STATION AND MAJOR WORK PROJECTS WHICH DETAIL THE SEQUENCE OF ACTIONS TO BE TAKEN FOR SAFELY BYPASSING GAS FACILITIES, FOR ISOLATING SEGMENTS OF PIPING FROM GAS UNDER PRESSURE, AND FOR TESTING THE ADEQUACY OF ISOLATION ACTIONS BEFORE ANY WORK IS PERFORMED ON THE ISOLATED SEGMENT. THESE PROCEDURES REQUIRE PREWORK MEETINGS TO EXPLAIN THE WORK TO BE PERFORMED BY EACH EMPLOYEE.\n\nAddressee Organization Type: P-Private Industry\n\nCommunication Date: 1985-05-03\n\nCommunication Type: Official Correspondence","truncated":false,"body_characters":3359}