NTSB Safety Recommendation P-92-014

NTSB safety recommendation P-92-014.

THE NTSB RECOMMENDS THAT THE SECRETARY OF THE NAVY: EVALUATE THE NAVY'S GAS PIPELINE PROGRAM TO IDENTIFY AND CORRECT ANY DEFICIENT DESIGN, CONSTRUCTION, OPERATION, AND MAINTENANCE PROCEDURES; INSPECT NAVY GAS PIPELINE SYSTEMS TO IDENTIFY AND CORRECT ANY CONDITIONS THAT DO NOT COMPLY WITH NAVY GAS PIPELINE SYSTEM POLICIES AND PRACTICES; AND, IF NECESSARY, IMPLEMENT A PROGRAM FOR PERIODICALLY ASSESSING COMPLIANCE AT ALL COMMAND LEVELS WITH NAVY GAS PIPELINE SAFETY POLICIES AND STANDARDS,

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 1992-05-01

Adopted Date: 1992-04-08

Overall Date Closed: 2002-09-13

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 Navy

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2002-09-13

Addressee Acronym: USN

Addressee Organization Type: G-Federal Government

Communication Date: 1992-07-14

Communication Type: Official Correspondence

Communication Contents: WE HAVE REVISED THE NAVY'S GUIDE SPECIFICATIONS TO UPDATE THE SELECTION OF PERMISSIBLE PIPELINE MATERIALS AND TO STRENGTHEN THE SECTION ON ABANDONED GAS LINES. WE ARE WORKING CLOSELY WITH THE ARMY, AIR FORCE, AND THE TRANSPORTATION SAFETY INSTITUTE IN DEVELOPING STANDARDS FOR GAS SYSTEM PERSONNEL, AS WELL AS TRAINING COURSES TO MEET THEM. WE ARE ALSO PARTICIPATING IN THE DEVELOPMENT OF A TRI-SERVICE OPERATIONS AND MAINTENANCE MANUAL ON NATURAL GAS SYSTEMS. THE NAVFAC WILL BE ASSISTING NAVY AND MARINE CORPS ACTIVITIES IN ASSESSING THE CONDITION OF THEIR NATURAL GAS SYSTEMS.

Addressee Acronym: USN

Addressee Organization Type: G-Federal Government

Communication Date: 2002-09-13

Communication Type: Official Correspondence

Communication Contents: Notation 5431C classified P-923-14 "Closed-Acceptable Action." Contact made with Naval Facilities Engineering Command and it was found that the guidance publications had been completed long ago. A review of the NAVFAC web site found the publication 0525-LP-173-2240, "Maintenance and Operation of Gas Systems." This document addresses the recommendation.

Addressee Acronym: USN

Addressee Organization Type: G-Federal Government

Communication Date: 1992-09-10

Communication Type: Official Correspondence

Communication Contents: THE BOARD UNDERSTANDS THAT THE NAVY HAS REVISED ITS GUIDE SPECIFICATIONS TO UPDATE THE SELECTION OF PERMISSIBLE PIPELINE MATERIALS & TO STRENGTHEN THE SECTION ON ABANDONED GAS LINES. ADDITIONALLY, STANDARDS FOR GAS SYSTEM PERSONNEL & RELATED TRAINING COURSES ARE BEING DEVELOPED. THE NAVAL FACILITIES ENGINEERING COMMAND WILL TAKE THE LEAD IN ASSESSING THE CONDITION OF NAVY & MARINE CORPS NATURAL GAS SYSTEMS, REVIEWING THE AS-BUILT NATURAL GAS SYSTEM DRAWINGS, & EVALUATING THE CONDITION OF THE SYSTEMS IN ORDER TO DEVELOP RECOMMENDATIONS FOR PROPER MAINTENANCE PROCEDURES. THE BOARD HAS CLASSIFIED RECOMMENDATION P-92-14 AS "OPEN--ACCEPTABLE RESPONSE" & WOULD APPRECIATE RECEIVING INFORMATION ON THE RESULTS OF THE GAS SYSTEM ASSESSMENTS & A COPY OF THE STANDARDS DEVELOPED FOR GAS SYSTEM PERSONNEL.