NTSB Safety Recommendation P-92-010

NTSB safety recommendation P-92-010.

THE NTSB RECOMMENDS THAT THE SECRETARY OF THE ARMY: DEVELOP AND CONDUCT EMPLOYEE TRAINING AND TESTING PROGRAMS TO ANNUALLY QUALIFY EMPLOYEES RESPONSIBLE FOR TASKS, INCLUDING EMERGENCY RESPONSE ONES, THAT MAY AFFECT THE SAFETY OF GAS PIPELINE 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.

Keywords: Training and Education

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: IN THE PLANNING STAGE IS THE DEVELOPMENT OF A REVIEW PROGRAM FOR PERSONNEL QUALIFICATIONS STANDARDS, THAT WILL BE UTILIZED BY SUPERVISORS TO ASSURE GAS SYSTEM PERSONNEL HAVE THE NECESSARY KNOWLEDGE AND SKILLS AND, TO IDENTIFY ANY NECESSARY TRAINING REQUIREMENTS. THE GAS SYSTEM SAFETY PROCEDURES REVIEWS BEING DEVELOPED BY THE U.S. ARMY SAFETY CENTER, WILL SPECIFICALLY ADDRESS ISSUES AFFECTING SAFETY OF NATURAL GAS SYSTEMS, INCLUDING TRAINING, QUALIFICATIONS, MANAGEMENT, AND EMERGENCY RESPONSE.

Addressee Acronym: DA

Addressee Organization Type: G-Federal Government

Communication Date: 1993-03-26

Communication Type: Official Correspondence

Communication Contents: EVALUATION OF THE ABILITY OF GAS SYSTEM WORKERS IS ACCOMPLISHED AS PART OF THE ANNUAL PROCESS OF PERFORMANCE EVALUATIONS FOR ALL INSTALLATION PERSONNEL. DURING THE STAFF ASSISTANCE VISIT PROGRAM EVALUATION BY HEADQUARTERS, DOA, AND MAJOR ARMY COMMAND PERSONNEL GAS SYSTEM OPERATOR QUALIFICATIONS AND TRAINING IS A TOPIC OF REVIEW. THE ANNUAL REVIEW OF ENGINEER OPERATIONS BY THE INSTALLATION SAFETY OFFICE WILL ALSO ADDRESS GAS SYSTEM OPERATOR QUALIFICATIONS AND TRAINING AND APPROPRIATE RECOMMENDATIONS WILL BE PROVIDED.

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 THE ARMY IS DEVELOPING A GAS SYSTEM SAFETY PROCEDURES REVIEW PROGRAM THAT WILL INCLUDE TRAINING, QUALIFICATIONS, MANAGEMENT, AND EMERGENCY RESPONSE PROCEDURES. FURTHERMORE, THE SAFETY BOARD ASSUMES FROM GENERAL SOBKE'S RESPONSE THAT HIS NEWLY CREATED REVIEW PROGRAM WILL INCLUDE THE ESTABLISHMENT OF TRAINING AND TESTING PROGRAMS DESIGNED TO ANNUALLY QUALIFY GAS DISTRIBUTION EMPLOYEES TO PERFORM THEIR RESPONSIBLE TASKS. PENDING IMPLEMENTATION OF THIS REVIEW PROGRAM, SAFETY RECOMMENDATION P-92-10 WILL BE 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 NEWLY CREATED EMPLOYEE REVIEW PROGRAM INCLUDES ESTABLISHING TRAINING & TESTING PROGRAMS DESIGNED TO ANNUALLY QUALIFY GAS DISTRIBUTION EMPLOYEES TO PERFORM TASKS FOR WHICH THEY ARE RESPONSIBLE. ADDITIONALLY, THE ANNUAL REVIEW OF ENGINEER OPERATIONS BY THE INSTALLATION SAFETY OFFICE WILL ADDRESS GAS SYSTEM OPERATOR QUALIFICATIONS & TRAINING. BASED ON THIS INFO, P-92-10 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."