NTSB Safety Recommendation P-92-006

NTSB safety recommendation P-92-006.

THE NTSB RECOMMENDS THAT THE SECRETARY OF THE ARMY: REQUIRE THAT GAS PIPELINE SYSTEMS THAT ARE OWNED OR OPERATED BY THE ARMY BE MANAGED BY PERSONS QUALIFIED BY EXPERIENCE AND TRAINING IN GAS DISTRIBUTION SYSTEM DESIGN, CONSTRUCTION, AND OPERATIONS.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 1992-05-01

Adopted Date: 1992-04-08

Overall Date Closed: 1993-12-13

Synopsis: ON DECEMBER 9, 1990, A GAS SYSTEM VALVE BETWEEN ONE OF FORT BENJAMIN HARRISON'S GAS DISTRIBUTION SYSTEMS AND A DISCONTINUED STEEL GAS SYSTEM SEGMENT WAS INADVERTENTLY OPENED, ALLOWING NATURAL GAS TO ENTER RESIDENTIAL BUILDINGS THAT HAD PREVIOUSLY RECEIVED THEIR GAS FROM THE DISCONTINUED SEGMENT. GAS ACCUMULATING IN BUILDING 1025 OF HARRISON VILLAGE WAS IGNITED BY ONE OF MANY AVAILABLE SOURCES, SUCH AS ELECTRICAL SWITCHES AND APPLIANCES, AND THE RESULTING EXPLOSION KILLED 2 OCCUPANTS AND INJURED 24 OTHER PERSONS. ONE BUILDING WAS DESTROYED, AND TWO WERE DAMAGED.

Probable Cause: Failure of the Army to construct, maintain, and operate the Fort's gas distribution system in accordance with its own and the industry's standards.

Ntsbnumber: DCA91MP002

Report Number: PAR-92-01

Addressee Name: United States Department of War, Department of the Army

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 1993-12-13

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-03-26

Communication Type: Official Correspondence

Communication Contents: AN AREA OF MAJOR INTEREST TO THE ARMY IS QUALITY TRAINING FOR GAS SYSTEM PERSONNEL. AS ADDRESSED IN THE REFERENCED LETTER, THE TSI HAS BEEN DEVELOPING THIS REQUIREMENT. THE COURSE DEVELOPMENT IS NOW COMPLETE. INITIAL FEEDBACK HAS SHOWN A HIGH DEGREE OF INTEREST IN ATTENDING THIS TRAINING COURSE.

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-10-19

Communication Type: Official Correspondence

Communication Contents: THE ADDITIONAL INFORMAION FOR RECOMMENDATION P-92-6, RELATING TO GAS SYSTEM TRAINING, IS PROVIDED AT ENCLOSRUE 1.

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-01-06

Communication Type: Official Correspondence

Communication Contents: THE SAFETY BOARD UNDERSTANDS THAT ARMY INSTALLATIONS AND PERSONNEL RESPONSIBLE FOR THE GAS DISTRIBUTION SYSTEM OPERATION AND MAINTENANCE HAVE BEEN PROVIDED AND UPDATED TECHNICAL MANUAL ON THE PROPER OPERATION, MAINTENANCE, AND REPAIR OF GAS DISTRIBUTION SYSTEMS. ADDITIONALLY, ARMY REGULATIONS HAVE BEEN REWRITTEN TO REQUIRE THE DEVELOPMENT OF SITE-SPECIFIC NATURAL GAS OPERATION AND MAINTENANCE PLANS TO ENSURE COMPLIANCE WITH THE TECHNICAL PROVISIONS OF 49 CODE OF FEDERAL REGULATIONS (CFR) PART 192. THE ARMY HAS TAKEN POSITIVE STEPS TOWARD MEETING THE INTENT OF THIS RECOMMENDATION. WE WOULD APPRECIATE, HOWEVER, RECEIVING INFORMATION ON THE ARMY'S PLANS TO ESTABLISH QUALIFICATION STANDARDS FOR THOSE PERSONNEL WHO OPERATE GAS DISTRIBUTION SYSTEMS. PENDING FURTHER RESPONSE, SAFETY RECOMMENDATION P-92-6 HAS BEEN CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-07-07

Communication Type: Official Correspondence

Communication Contents: THE BOARD NOTES THAT THE ARMY & THE TRANSPORTATION SAFETY INSTITUTE HAVE BEEN WORKING TOGETHER TO DEVELOP A COURSE ON OPERATION, MAINTENANCE, DESIGN, AND CONSTRUCTION REQUIREMENTS FOR GAS SYSTEM SAFETY. IN THAT REGARD, THE BOARD WOULD APPRECIATE LEARNING OF THE ARMY'S PLANS TO MAKE THIS TRAINING A REQUIREMENT FOR BOTH SUPERVISORS & GAS SYSTEM EMPLOYEES. PENDING FURTHER RESPONSE, RECOMMENDATION P-92-6 WILL REMAIN "OPEN--ACCEPTABLE RESPONSE."

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-12-13

Communication Type: Official Correspondence

Communication Contents: THE BOARD UNDERSTANDS THAT ARMY REGULATION 420-49 HAS BEEN MODIFIED ACCORDINGLY. THE BOARD ALSO UNDERSTANDS THAT THE ARMY WILL CONTINUE TO ADVISE INSTALLATION OF THE REGUIREMENT TO TRAIN GAS WORKERS AND TO RECOMMEND PARTICIPATION IN THE GAS SYSTEM SAFETY COURSE PRESENTED BY THE TRANSPORTATION SAFETY INSTITUE. BASED ON THIS INFORMATION, RECOMMENDATION P-92-6 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-03-25

Communication Type: Official Correspondence