# NTSB Safety Recommendation P-93-002

- **operation:** document
- **citation:** P-93-002
- **title:** NTSB Safety Recommendation P-93-002
- **source type:** guidance
- **agency:** National Transportation Safety Board
- **status:** guidance
- **official:** true
- **published on:** 1993-01-26
- **effective on:** 1993-01-26
- **summary:** THE NTSB RECOMMENDS THAT THE PEOPLE GAS LIGHT AND COKE COMPANY: DEVELOP PROCEDURES TO ENSURE THAT THE MAXIMUM SAFE SYSTEM PRESSURE IS NOT EXCEEDED WHEN THE PRESSURE IN A GAS SYSTEM IS BEING MANUALLY CONTROLLED.
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- **source url:** https://data.ntsb.gov/carol-main-public/sr-details/P-93-002
**body:**

NTSB safety recommendation P-93-002.

THE NTSB RECOMMENDS THAT THE PEOPLE GAS LIGHT AND COKE COMPANY: DEVELOP PROCEDURES TO ENSURE THAT THE MAXIMUM SAFE SYSTEM PRESSURE IS NOT EXCEEDED WHEN THE PRESSURE IN A GAS SYSTEM IS BEING MANUALLY CONTROLLED.

Priority: CLASS II

Overall Status: Closed - Acceptable Action

Issued Date: 1993-01-26

Adopted Date: 1993-01-05

Overall Date Closed: 1993-04-16

Synopsis: ON JANUARY 17, 1992, WHILE A CREW FROM PEOPLES GAS LIGHT AND COKE COMPANY (PEOPLES) WAS DOING ROUTINE ANNUAL MAINTENANCE WORK ON A MONITOR REGULATOR AT ONE OF ITS REGULATOR STATIONS, HIGH-PRESSURE GAS ENTERED A LOW-PRESSURE SYSTEM. THE GAS--UNDER AS MUCH AS 10 PSIG OF PRESSURE--ESCAPED THROUGH GAS APPLIANCES INTO HOMES AND OTHER BUILDINGS, WHERE IT WAS IGNITED BY SEVERAL UNIDENTIFIED SOURCES. THE RESULTING EXPLOSION AND FIRES KILLED 4 PEOPLE, INJURED 4, AND DAMAGED 14 HOUSES AND 3 COMMERCIAL BUILDINGS.

Probable Cause: Peoples Gas Light and Coke Company failure to adequately train its gas operations section employees

Ntsbnumber: DCA92MP004

Report Number: PAR-93-01-SUM

Addressee Name: Peoples Gas

Addressee Status: Closed - Acceptable Action

Addressee Date Closed: 1993-04-16

Addressee Organization Type: P-Private Industry

Communication Date: 1993-02-25

Communication Type: Official Correspondence

Communication Contents: WE HAVE MODIFIED OUR PROCEDURES FOR THE ANNUAL INSPECTION OF REGULATORS SO THAT THE TYPE OF INCIDENT WHICH OCCURRED ON JANUARY 17, 1992, CANNOT HAPPEN AGAIN. UNDER THE REVISED PROCEDURES FOR ANNUAL INSPECTIONS, THE COMPANY IS NOT USING A SINGLE BYPASS LINE AND IS NOT MANUALLY CONTROLLING THE PRESSURE. WE WILL REFLECT THE CHANGES TO OUR PROCEDURES DESCRIBED ABOVE IN REVISIONS TO OUR GAS OPERATIONS TRAINING MANUAL.

Addressee Organization Type: P-Private Industry

Communication Date: 1993-04-16

Communication Type: Official Correspondence

Communication Contents: THE BOARD NOTES THAT PEOPLES' PROCEDURES TO ENSURE THAT THE MAXIMUM SAFE SYSTEM PRESSURE IS NOT EXCEEDED HAVE BEEN MODIFIED SO THAT A SINGLE BYPASS LINE IS NOT USED, PRESSURE IS NOT MANUALLY CONTROLLED, & MAINTENANCE IS SCHEDULED WHEN THE SYSTEM CAN BE SHUT DOWN. PEOPLES IS INCLUDING THESE NEW PROCEDURES IN REVISIONS TO ITS GAS OPERATIONS TRAINING MANUAL. BASED ON THIS INFO, P-93-2 HAS BEEN CLASSIFIED "CLOSED--ACCEPTABLE ACTION."
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