NTSB Safety Recommendation P-92-008

NTSB safety recommendation P-92-008.

THE NTSB RECOMMENDS THAT THE SECRETARY OF THE ARMY: IDENTIFY AND CORRECT INACCURACIES AND OMISSIONS IN MAPS FOR GAS SYSTEMS THAT ARE OWNED OR OPERATED BY THE ARMY.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 1992-05-01

Adopted Date: 1992-04-08

Overall Date Closed: 1993-07-07

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: 1993-07-07

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1992-08-27

Communication Type: Official Correspondence

Communication Contents: DUE TO THE EXTENT OF REAL PROPERTY AND THE VOLUME OF CHANGES, MAP MAINTENANCE IS AN AREA OF DIFFICULTY AT ARMY INSTALLATIONS. MAPS OF ALL UTILITY SYSTEMS, BUILDINGS, ROADS, RAILROADS, AND OTHER FACILITIES REQUIRE CONTINUOUS UPDATING. TO ASSIST THE INSTALLATIONS, A TECHNICAL NOTE (TN) HAS BEEN PREPARED. THE TN PROVIDES RECOMMENDATIONS FOR DEVELOPMENT OF A PROCESS TO UPDATE AND MAINTAIN THE MAPS. AN EXPANDING USE OF COMPUTERIZED DRAFTING SYSTEMS WILL HELP THE ARMY MAP MAINTENANCE PROCESS.

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-03-26

Communication Type: Official Correspondence

Communication Contents: A SEPARATE REVIEW OF INSTALLATION SAFETY OFFICE HAS ALSO BEEN ESTABLISHED. ON A YEARLY BASIS, THE INSTALLATION SAFETY OFFICE WILL CONDUCT A REVIEW OF THE PROCEDURES EMPLOYED TO ASSURE THE SAFETY OF NATURAL GAS SYSTEMS. THE REVIEW WILL ASSIST THE INSTALLATION IN ASSESSING THE OVERALL CONDITION OF THE NATURAL GAS SYSTEM, WITH PARTICULAR EMPHASIS ON SYSTEM AND WORKER SAFETY. THE ACCURACY AND UPDATE STATUS OF THE GAS MAPS IS A SPECIFIC TOPIC OF REVIEW.

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-01-06

Communication Type: Official Correspondence

Communication Contents: THE SAFETY BOARD NOTES THAT THE ARMY HAS PREPARED A TECHNICAL NOTE WITH RECOMMENDATIONS FOR UPDATING AND MAINTAINING UTILITY MAPS AND HAS MADE CORRECTING GAS MAPS A HIGH PRIORITY. ALSO, THE ARMY IS EXTENDING ITS COMPUTERIZED DRAFTING SYSTEMS TO EXPEDITE MAP MAINTENANCE. THE SAFETY BOARD IS PLEASED THAT THE ARMY NOW HAS IN PLACE A PROGRAM THAT WILL CORRECT MAP DEFICIENCIES. HOWEVER, WE WOULD APPRECIATE RECEIVING PROGRESS REPORTS ON THE ARMY'S EFFORTS TO ACTUALLY IDENTIFY AND CORRECT INACCURACIES AND OMISSIONS IN ITS GAS SYSTEM MAPS. PENDING FURTHER RESPONSE, SAFETY RECOMMENDATION P-92-8 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 UNDERSTANDS THAT THE ARMY HAS MADE SUBSTANTIAL PROGRESS IN CORRECTING DEFICIENCIES IN UTILITY MAPS, & ARMY INSTALLATIONS HAVE ESTABLISHED A PROCESS FOR ANNOTATING WORKING DRAWINGS WITH CORRECTIONS & UPDATES TO ENSURE THAT EMERGENCY RESPONSE PERSONNEL HAVE ACCURATE GAS SYSTEM MAPS. BASED ON THIS INFO, P-92-8 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."