NTSB Safety Recommendation P-92-015

NTSB safety recommendation P-92-015.

THE NTSB RECOMMENDS THAT THE SECRETARY OF THE AIR FORCE: EVALUATE THE AIR FORCE'S GAS PIPELINE PROGRAM TO IDENTIFY AND CORRECT ANY DEFICIENT DESIGN, CONSTRUCTION, OPERATION, AND MAINTENANCE PROCEDURES; INSPECT AIR FORCE GAS PIPELINE SYSTEMS TO IDENTIFY AND CORRECT ANY CONDITIONS THAT DO NOT COMPLY WITH AIR FORCE GAS PIPELINE SYSTEM POLICIES AND PRACTICES; AND, IF NECESSARY, IMPLEMENT A PROGRAM FOR PERIODICALLY ASSESSING COMPLIANCE AT ALL COMMAND LEVELS WITH AIR FORCE 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: 2001-07-27

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 Air Force

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 2001-07-27

Addressee Acronym: USAF

Addressee Organization Type: G-Federal Government

Communication Date: 2001-04-13

Communication Type: Official Correspondence

Communication Contents: Letter Mail Controlled 04/25/2001 10:15:41 AM MC# 2010350 The NTSB's recommendations were valuable in refocusing the direction of our natural gas maintenance program and served as a wake-up call to many of our bases. We incorporated the recommendations into Air Force Instruction 32-1069, Gas Supply and Distribution. In addition, the Services collaborated to obtain training from the Transportation Safety Institute, and we incorporated the NTSB recommendations into Air Force training at Sheppard AFB. Today, as we begin to privatize natural gas systems at Air Force installations, we have incorporated the essence of the Guidance Manualfor Operators of Natural Gas Systems and 49 CFR Part 192, Transportation of Natural and Other Gas by Pipeline, Minimum Federul Safety Standards into our statements of work.

Addressee Acronym: USAF

Addressee Organization Type: G-Federal Government

Communication Date: 2001-03-09

Communication Type: Official Correspondence

Communication Contents: To date, the Safety Board has received no information from the Air Force and would appreciate learning what action has been taken to implement Safety Recommendation P-92-15. Please cite the recommendation number above in your response.

Addressee Acronym: USAF

Addressee Organization Type: G-Federal Government

Communication Date: 2001-07-27

Communication Type: Official Correspondence

Communication Contents: The Safety Board is pleased that the Air Force has completed the requested evaluation and incorporated the Board's recommendation into Air Force Instruction 32-1069, Gas Supply and Distribution. In addition, a joint services coalition collaborated to obtain training from the Transportation Safety Institute and incorporated the Safety Board's recommendations into Air Force training at Sheppard Air Force Base. The Air Force is privatizing natural gas systems at Air Force installations, and has incorporated the essence of the Guidance Manual for Operators of Natural Gas Systems and Title 49 Code of Federal Regulations Part 192, Transportation of Natural and Other Gas by Pipeline, Minimum Federal Safety Standards, into its statements of work. Because the Air Force has taken action as requested, Safety Recommendation P-92-15 is classified "Closed-Acceptable Action."