NTSB Safety Recommendation P-92-009

NTSB safety recommendation P-92-009.

THE NTSB RECOMMENDS THAT THE SECRETARY OF THE ARMY: INITIATE ANNUAL ASSESSMENTS OF ADHERENCE TO DESIGN, CONSTRUCTION, MAINTENANCE, AND OPERATIONS STANDARDS APPLICABLE TO GAS PIPELINE SYSTEMS THAT ARE OWNED OR OPERATED BY THE ARMY, AND REQUIRE THAT ALL IDENTIFIED DEFICIENCIES BE CORRECTED.

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: TRAINING BASED ON 49 CFR, PART 192 IS TAUGHT AT THE STATE LEVEL BY DEPT. OF TRANSPORTATION PERSONNEL. THE INSTALLATIONS HAVE BEEN INFORMED OF THE AVAILABILITY OF THIS TRAINING, WITH THE RECOMMENDATION THAT GAS SYSTEM PERSONNEL ATTEND. WITH EXPOSURE TO 49 CFR, PART 192 REQUIREMENTS, AND IN PARTICULAR ANY NEW DEVELOPMENTS, ARMY PERSONNEL WILL BE BETTER ABLE TO ASSESS CONDITIONS AFFECTING THEIR GAS SYSTEMS. PERIODIC REVIEW OF GAS DISTRIBUTION SAFETY PROCEDURES: THIS PROGRAM IS CURRENTLY BEING DEVELOPED BY THE U.S. ARMY CENTER FOR SAFETY OVERSIGHT OF NATURAL GAS AND OTHER ENERGY SYSTEMS.

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-03-26

Communication Type: Official Correspondence

Communication Contents: A SURVEY OF ARMY INSTALLATIONS COMPLETED IN SEPT. 1992 CONFIRMS THAT CONSIDERABLE IMPROVEMENT HAS BEEN MADE IN THE PHYSICAL CONDITION OF GAS SYSTEMS AND IN THE PROCEDURES TO EVALUATE AND ENSURE THE SAFETY OF NATURAL GAS SYSTEMS. INCREASED ATTENTION IS BEING GIVEN TO SYSTEM REPAIR AND REPLACEMENT PROJECTS ALREADY IN PROGRESS. THE INSTALLATION SAFEY OFFICE WILL CONDUCT A REVIEW OF THE PROCEDURES EMPLOYED TO ASSURE THE SAFETY OF NATURAL GAS SYSTEMS.

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-01-06

Communication Type: Official Correspondence

Communication Contents: WE WOULD APPRECIATE RECEIVING INFORMATION ON THE ARMY'S PLANS TO INITIATE ANNUAL ASSESSMENTS OF ITS GAS PIPELINE SYSTEMS. PENDING FURTHER RESPONSE, SAFETY RECOMMENDATION P-92-9 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 IS PLEASED TO LEARN THAT THE ARMY'S INSTALLATION SAFETY OFFICE WILL CONDUCT A SEPARATE ANNUAL REVIEW OF INSTALLATION ENGINEERING OPERATIONS. BASED ON THIS INFO, P-92-9 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."